The Ongoing Battle: How Prior Authorization Continues to Deny Americans Life-Saving Care

A Family’s Desperate Fight for Treatment

Sheldon Ekirch knows all too well what it means to be let down by the American healthcare system. The 31-year-old from Henrico, Virginia, spent two exhausting years locked in battle with her insurance company, Anthem, fighting for coverage of a treatment that could dramatically improve her quality of life. Ekirch suffers from small-fiber neuropathy, a devastating condition that makes her limbs feel as though they’re constantly on fire. Her doctors recommended blood plasma infusions called intravenous immunoglobulin, or IVIG, which has shown promise in alleviating symptoms for patients like her. But Anthem repeatedly denied coverage for the treatment, which costs approximately $10,000 per infusion. The company’s refusals forced Ekirch’s parents into an impossible position: watch their daughter suffer or drain their life savings. Choosing love over financial security, they withdrew nearly $90,000 from her father’s retirement account to pay for the treatments out-of-pocket. Then, in February, everything changed. An external review conducted by the Virginia Bureau of Insurance overturned Anthem’s denial, finally obligating the insurance company to cover the treatment. The family’s reaction was overwhelming. “My mom was sobbing. My dad was on his knees, sobbing. I don’t think I’ve ever seen him cry like that,” Ekirch recalled. The relief was palpable, yet mixed with the trauma of what they’d endured. “I think I’m in shock from it all,” she admitted.

Empty Promises From the Insurance Industry

Despite repeated pledges to reform the prior authorization process, meaningful change remains frustratingly elusive for millions of Americans. In June of last year, Trump administration officials stood before cameras and announced that major health insurance companies had committed to simplifying prior authorization—the gatekeeping process that requires patients or doctors to obtain preapproval from insurers before proceeding with medical care. The insurers promised to reduce the number of services requiring preapproval, speed up decision times, and provide clear explanations when denials occur. These commitments sounded encouraging on paper, but when KFF Health News followed up with more than a dozen major insurers who signed the pledge in February, half couldn’t—or wouldn’t—provide specific examples of healthcare services they’d removed from prior authorization requirements. The lack of transparency raises serious questions about whether these companies ever intended to follow through on their promises. Matt Toresco, CEO of Archo Advocacy, a patient advocacy and consulting company, was blunt in his assessment: “They have no desire to do what’s in the best interest of the patient if it’s going to hurt their pockets.” He pointed out that insurance companies’ primary obligation isn’t to patients—it’s to Wall Street shareholders. This fundamental conflict of interest helps explain why voluntary reforms have failed to materialize into real relief for patients.

Minimal Progress, Maximum Skepticism

When pressed for specifics, most insurance companies offered vague assurances rather than concrete examples of change. AHIP, the health insurer trade group that issued statements about progress, couldn’t provide information about specific treatments, medications, or procedures that member companies have released from prior authorization since signing the pledge. Kelly Parsons, a spokesperson for the Blue Cross Blue Shield Association representing 33 independent companies, promised “additional progress updates coming out later this spring” but offered nothing substantive. Several Blue Cross and Blue Shield companies covering patients across eight states either ignored questions entirely or simply referred reporters back to the association. A few insurers did cite specific changes. Aetna CVS Health began “bundling” prior authorizations for musculoskeletal procedures and certain cancer treatments, allowing providers to file one authorization instead of several for a patient’s course of treatment. Humana removed prior authorization requirements for diagnostic colonoscopies among other services. UnitedHealthcare, which faced intense scrutiny following the fatal shooting of one of its executives in late 2024, removed requirements for certain imaging and ultrasound procedures starting January 1. However, healthcare advocates remain deeply skeptical that these modest adjustments represent meaningful reform. Dr. Bobby Mukkamala, president of the American Medical Association, noted that insurers made similar promises in 2018 when various health industry groups announced a partnership to improve prior authorization. Yet the process remains “costly, inefficient, opaque, and too often hazardous for patients,” he wrote. “Transparency is essential so everyone can see whether real reforms are happening,” he emphasized.

The Human Cost of Bureaucratic Barriers

While politicians and insurance executives issue press releases about incremental improvements, real people continue suffering through the prior authorization maze, particularly those with chronic conditions requiring ongoing treatment. According to a recent KFF poll, 39% of patients with chronic conditions identified prior authorization as “the single biggest burden” in receiving care. These aren’t just statistics—they’re stories of ordinary Americans fighting for their lives against faceless bureaucracies. Payton Herres, a 25-year-old from Dayton, Ohio, received a heart transplant in 2012, requiring her to take antirejection medication for the rest of her life. She’d been taking the same drug for more than a decade without issue when Anthem suddenly began denying coverage in 2024. “I’ve been with Anthem my entire life, and then, all of a sudden—I don’t know what happened—they just started denying me over and over,” she said. “I almost ran out of medication.” After KFF Health News contacted Anthem about Herres’s case, a spokesperson confirmed the company approved the medication, acknowledging they hadn’t considered her treatment history when issuing the denials. But the approval is temporary—Herres will need new authorization in September, leaving her anxious about whether she’ll face another fight for the medication keeping her transplanted heart functioning. “Are they going to deny other things, too?” she wondered. “I hope I don’t have to keep fighting like this for the rest of my life.”

Fighting to Prove You Deserve to Live

Anna Hocum’s experience illustrates how prior authorization can literally become a matter of life and death. The 25-year-old Milwaukee resident has a rare genetic condition that progressively destroys lung function. In 2024 and 2025, her insurer repeatedly denied coverage for expensive treatment proven to slow the disease’s progression. “I just thought I was going to die,” Hocum said. “I was fighting to survive, and then I was fighting to convince someone that I deserved to survive.” Like Ekirch’s family, Hocum’s parents paid for treatments while appealing the denials. Friends and family organized a GoFundMe campaign that raised more than $30,000 to help cover costs. Then, last spring, her insurer reversed the denial without explanation—a bureaucratic about-face as mysterious as the initial rejection. But the approval lasts only 12 months, meaning Hocum will need to secure another prior authorization this year. “It is scary,” she admitted. “It’s not guaranteed that it’ll be accepted.” The psychological toll of this uncertainty compounds the physical burden of her disease. Every denial, every appeal, every unexplained reversal reinforces the message that her life is subject to cost-benefit analysis by people who’ve never met her and never will.

An Uncertain Future and Systemic Problems

Even Sheldon Ekirch’s hard-won victory came with bitter complications. While it’s a “huge relief” that Anthem must now cover her IVIG treatments, her mother doesn’t know if or how the family can recover the $90,000 already spent from retirement savings. The letter confirming the external reviewer’s decision stated the authorization would be valid for one year beginning September 25, 2025—meaning more uncertainty lies ahead. Ekirch was struck by the company’s tone in the approval letter. “They act as though they are a benevolent organization doing me a favor,” she said. “In reality, they fought me tooth and nail every step of the way, to the point that they made my life a living hell.” Her access to treatment faces yet another threat: her COBRA coverage through Anthem expires in late March. Starting in April, she’ll need to transition to a new insurance plan, likely triggering another prior authorization battle. “I just am so afraid that I don’t have the strength to go through and do what it takes to fight this battle again,” Ekirch said. Her exhaustion reflects a fundamental flaw in American healthcare: patients already weakened by illness must become expert advocates, appeals specialists, and warriors against bureaucracy just to access doctor-recommended care. The insurance industry’s voluntary reform pledges ring hollow against these lived experiences. Without regulatory enforcement, transparency requirements, or accountability measures, millions of Americans will continue facing denial, delay, and financial devastation in their pursuit of medical treatment that could save or dramatically improve their lives.