New 2026 Study: Insurance Prior Authorization Delays Spine Surgery, Without Saving Money
A first of its kind analysis presented at the 2026 AAOS Annual Meeting found that most denied spine surgery claims get approved anyway, just weeks later, raising fresh questions about why conservative care documentation matters so much upfront.
Key takeaways
- Researchers reviewed more than 7,000 elective spine surgery requests from 2021 to 2024 and found insurers initially denied about 7 percent of them.
- Of those denied, 81.3 percent were eventually approved anyway, though it took nearly 16 days on average before that approval came through.
- The single most common reason for denial, cited in 30 percent of cases, was missing documentation of six weeks of physical therapy.
- The study found no evidence that the delays produced real cost savings for insurers, only extra paperwork and prolonged pain for patients.
Figures drawn from the OrthoCarolina Research Institute analysis presented at the 2026 AAOS Annual Meeting.
What the study looked at
A research team from OrthoCarolina Research Institute, led by Rob Turk, MD, MBA, and Brad Segebarth, MD, set out to answer a question a lot of patients quietly wonder about: when an insurance company denies a recommended spine surgery, does that denial usually stick, or does it just delay things? The team retrospectively reviewed 7,071 prior authorization requests for elective lumbar and cervical spine surgery submitted between January 2021 and December 2024, all recommended by board certified orthopedic spine surgeons for patients with degenerative spine disease.
The findings were shared this past March at the orthopaedic surgery field's big annual gathering in New Orleans, and they were described as a first of its kind look at what actually happens after a denial letter arrives, not just how often denials occur.
Most denials did not hold up
Insurers denied coverage for 460 of the requests, close to 7 percent overall. But the more striking number came next: 374 of those patients, or 81.3 percent, ultimately had their claim reversed and went on to receive the recommended surgery anyway. The catch was timing. The average delay before approval came through was 15.7 days, with a wide range reflected in a standard deviation of 33 days, meaning some patients waited considerably longer.
That gap matters for anyone living with disabling back or neck pain. Dr. Turk was quoted describing the human side of the numbers plainly, noting that patients had to live with pain that restricted their work, family and community activities during that stretch, even though most of them were approved for the very procedure that had first been turned down.
Why claims were denied in the first place
The study broke down the reasons behind the initial denials, and the results point to something patients and their care teams can actually act on. The largest single category, 30 percent of denials, cited a lack of documented six week physical therapy trial before surgery was considered. Another 26.5 percent were denied because the insurer judged the procedure not medically necessary based on the records submitted, and 15 percent were flagged for missing documentation of a smoking cessation attempt. Roughly 31 percent of denied cases required a peer to peer conversation between physicians before being resolved.
Procedure type mattered too. Stand alone lumbar decompression carried a 15.4 percent denial rate, while lumbar decompression paired with instrumented fusion was denied more often, at 27.8 percent, likely reflecting the higher scrutiny that more complex fusion procedures tend to draw from reviewers.
- 30 percent of denials: incomplete six week physical therapy documentation
- 26.5 percent of denials: procedure deemed not medically necessary
- 15 percent of denials: no documented smoking cessation attempt
- 30.9 percent of denials: required a peer to peer physician review before resolution
No cost savings, just extra steps
One of the study's more pointed conclusions is that all this friction did not appear to translate into real savings for payers. Dr. Turk framed it as health plans continuing to pay for the same eventual care, just later, rather than approving procedures that could have helped patients sooner. In other words, the paperwork burden functioned less like a cost control measure and more like a waiting period that most patients cleared eventually anyway.
For a practice like ours that leans heavily on non-surgical, conservative approaches first, this data lands as a reminder rather than a surprise. Thorough documentation of physical therapy, activity modification, and other conservative steps is not just an insurance hoop. It is also, per these numbers, one of the most common gaps that slows people down when surgery genuinely is the next step.
What this can mean for your own care timeline
If you are working through a course of conservative back or neck care, whether that is physical therapy, activity adjustments, or other non-surgical approaches, keeping a clear record of what you tried and for how long is not just administrative housekeeping. This research suggests it can be the difference between a smooth authorization and weeks of avoidable back and forth if a specialist ever recommends a more advanced procedure down the line.
This article is informational only and is not medical advice, and nothing here should be read as a promise of any particular outcome. If ongoing back or neck pain has you wondering what conservative options might fit your situation, or you want a second look at where you stand in your own care timeline, our team is happy to sit down for a consult and talk through it together.
Keeping your care documentation on track
Based on what the study identified as the most common denial triggers, here are practical things to keep organized if you are working through conservative spine care.
- Track your physical therapy timeline: Keep dated records of when sessions started and how many weeks of therapy you completed, since incomplete PT documentation was the top denial reason in the study.
- Ask for written visit summaries: Request that your provider's notes clearly describe what conservative treatments were tried and how you responded, so the record is easy for a reviewer to follow.
- Note any lifestyle steps taken: If smoking cessation or activity modification was discussed, keep a record of that conversation and any follow through.
- Ask what documentation an insurer typically wants: Every plan is different, so asking your care team what a given insurer usually requires can help you gather the right paperwork early.
- Keep copies of imaging and specialist notes: Having your own copies of MRI reports and specialist evaluations on hand can speed up a peer to peer review if one is needed.
- Stay in touch with your care team during a review: If a claim is under review, checking in regularly can help you learn quickly whether more documentation is needed.
Frequently Asked Questions
Does this study mean insurance will always deny spine surgery at first?
No. The study found most requests, roughly 93 percent, were approved on the initial review. Denials happened in a minority of cases, and most of those were eventually reversed.
Why does physical therapy documentation matter so much?
In this analysis it was the single most common reason cited for an initial denial, showing up in 30 percent of denied cases, which suggests thorough records of conservative care can help avoid unnecessary delays.
Does a denial mean surgery was not actually needed?
Not necessarily. The study found 81.3 percent of initially denied patients eventually had their claim reversed and went on to have the recommended surgery, just after an added delay.
Is this article medical or insurance advice?
No. This is informational only, not medical or insurance advice, and it does not promise any particular outcome for your situation. For specific guidance, talk with your care team or insurer directly.