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    Prior Authorization

    Payer requirement for approval before a service or device is covered.

    Reviewed by Christian Espinosa, Founder, Blue Goat CyberLast reviewed May 5, 2026

    Definition

    Prior authorization (PA) is a payer process requiring providers to obtain approval - based on medical necessity criteria - before a service, procedure, or device is covered. Common for high-cost devices, advanced imaging, and many DTx/RPM services.

    What this means in practice

    PA is a major friction point for new technology adoption; clinical pathway and PA support tools are increasingly part of the manufacturer commercial model.
    Common pitfalls
    • •Underestimating PA denial rates and appeal timelines when modeling commercial uptake.

    Primary references

    3 sources
    Link health: 2 verified 1 bot-blocked· last checked 2026-05-09
    CMS·1AMA·1AdvaMed·1
    1. 1
      CMS PA reform
      Verified
      CMScms.gov
    2. 2
      AMA CPT Resources
      Bot-blocked
      AMAama-assn.org
    3. 3
      AdvaMed - Payment & Coverage
      Verified
      AdvaMedadvamed.org

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