Prior Authorizations — How to Win Approvals

Prior Authorizations — How to Win Approvals means understanding the insurer’s decision-making process before treatment begins.
In plain English, it helps you see:

• What procedures and medications require prior authorization
• Why insurers deny requests (and how to prevent it)
• How medical notes, diagnosis codes, and timing influence outcomes
• How IVF, donor cycles, or surrogacy interact with insurer rules
• Which documents the insurer considers “proof” of medical necessity

When done correctly, prior authorizations create a predictable financial line—when done poorly, they cause delays, denials, and avoidable out-of-pocket spend.

Who It Helps

This guide is especially useful for intended parents who:

• Are planning IVF, egg freezing, donor cycles, PGT-A, or surrogacy
• Have insurance coverage—but aren’t sure how to activate it
• Experienced past denials or delays
• Want to avoid paying for meds or procedures upfront
• Have conditions (age > 35, low AMH, male-factor issues, fibroids, endometriosis) that must be correctly documented

It’s also important for those with:

• Complex reproductive histories
• Prior failed cycles (which require justification for repeat attempts)
• Out-of-state clinics
• Employer fertility benefits tied to strict criteria

Step-by-Step: A Simple Sequence That Reduces Risk & Stress

Gather Your Diagnostic Evidence (Week 0–1)

Insurers approve based on data, not assumptions.
Collect:

• Ovarian reserve labs
• Semen analysis
• Ultrasounds / imaging
• Past cycles and outcomes
• Relevant diagnoses (PCOS, male-factor, diminished reserve, uterine factors)

Outcome: You have the evidence that supports “medical necessity.”

Confirm Exactly Which Services Need Prior Auth (Week 0–2)

Typical items requiring approval:

• IVF retrieval
• Trigger meds, gonadotropins, progesterone
• Genetic testing (PGT-A)
• Hysteroscopy, laparoscopy
• Surrogate-related procedures (rarely covered but still reviewed)

Outcome: No surprises at the pharmacy counter or clinic billing desk.

Submit a Complete Prior Auth Packet (Week 1–3)

A winning packet includes:

• Correct diagnosis codes
• Treatment plan
• Medical necessity letter
• Supporting labs and imaging
• Cycle dates and dosing protocol
• Previous treatment history (if applicable)

Outcome: The insurer has everything needed to say “yes” on the first review.

Track Timelines & Escalate Early (Week 2–4)

Set checkpoints:

• Day 5: Confirm receipt
• Day 10: Request status update
• Day 14: Escalate to medical review
• Day 21: Appeal or expedited review

Outcome: No cycle is delayed waiting for paperwork.

Sync Authorizations With Cycle Scheduling (Ongoing)

• Med approvals must align with stimulation start
• Procedure approvals must align with retrieval window
• Plan-year resets may affect deductible and OOP max

Outcome: Financial and medical timelines stay coordinated.

Pros & Cons

Pros

• Reduces out-of-pocket surprises
• Prevents pharmacy delays for critical meds
• Improves cycle timing
• Ensures insurance is actually usable
• Helps clinics bill correctly

Cons

• Requires paperwork and patience
• Can delay treatment if started late
• Insurer rules may feel rigid
• Some services (e.g., donor eggs, surrogacy) are often excluded regardless

Costs & Logistics

Line Items Affected by Prior Auth

• IVF procedures
• Medications (large cost driver)
• Diagnostics (HSG, ultrasounds, labs)
• Genetic testing
• Surrogate screenings (if any portion is covered)

Escrow & Cash-Flow Links

• If prior auth is denied, some costs shift to escrow or patient pay
• Medication denials can swing budgets by thousands
• Delays create additional monitoring costs

The Key Logistics

• Prior auth usually expires in 30–90 days
• Clinic billing codes must match what was authorized
• Pharmacy benefits often require separate approval
• Employer benefits may need receipts for reimbursement

What Improves Outcomes

Materially Improves

• Submitting a complete packet the first time
• Using clear, evidence-based medical necessity letters
• Correct diagnosis codes (most denials happen here)
• Coordinating between insurance, clinic, and pharmacy
• Starting the process 2–4 weeks before stimulation
• Asking for an expedited review when medically time-sensitive

Rarely Improves

• Calling without documentation
• Submitting incomplete labs
• Relying on verbal confirmation
• Starting meds before approval
• Assuming surrogacy-related medical care will be covered

Case Study: From Denials to Predictable Approvals

A patient with diminished ovarian reserve planned IVF with PGT-A.
Her first cycle was delayed because:

• The clinic used a non-specific diagnosis code
• Meds were sent to a pharmacy requiring separate pre-auth
• The insurer requested proof of medical necessity

What changed:
We reorganized the packet:

• Added AMH, AFC, and prior fertility history
• Included a specific diagnosis
• Provided a detailed treatment plan with dates
• Requested an expedited review

Outcome:
Approval in 48 hours, full coverage of meds, and no cycle delays.
On the second cycle, the clinic reused the approved codes and all approvals were immediate.

Mistakes to Avoid

• Starting the prior auth process too late
• Missing required labs or imaging
• Using vague diagnosis codes
• Not checking pharmacy benefit rules
• Assuming approval from one cycle automatically applies to the next
• Ignoring expiration dates
• Scheduling procedures before confirmation

FAQs

Q: How long does prior authorization take?

Ans : Typically 7–21 days. With expedited review, sometimes 24–72 hours.

Q: Why do denials happen?

Ans : Missing documentation, incorrect codes, unclear medical necessity, or excluded services.

Q: Are donor or surrogacy services ever approved?

Ans : Rarely. They are often excluded by definition, regardless of medical need.

Q: Can I appeal?

Ans : Yes—strong documentation and clear medical rationale improve success.

Q: Do approvals transfer between clinics?

Ans : Usually no. New clinic = new codes = new authorization.

Next Steps

• Free 15-min nurse
• consult Upload your labs for review
• Get a personalized cost breakdown for your case

Related Links

• Financing insurance benefits
• Intended Parents
• Become a Surrogate
• Fixed‑Cost Packages
• SART
• CDC ART
• ASRM