Initial prior authorization denial is associated with increasingly prolonged approval times in outpatient orthopaedic surgery: a 2017-2022 comparative cohort study

Background: Prior authorization (PA) is widely used by insurers to manage healthcare costs but may delay care, especially after an initial denial. While physician surveys report rising administrative burden from PA, objective data quantifying how denials affect approval timelines remain limited. This study evaluated whether an initial PA denial was associated with longer approval times for outpatient orthopaedic surgery, and whether this delay in care worsened between 2017 and 2022. Methods: We conducted a retrospective cohort study of PA processing timelines for outpatient shoulder, elbow, hip, and knee surgeries performed by a single orthopaedic surgeon in 2017 and 2022. Cases were categorized as Denial (initial denial followed by eventual approval) or No Denial (approved without appeal or not requiring PA). Welch's two-sample t-tests with 95% confidence intervals compared approval wait times between groups and years. Results: A total of 169 surgeries were included (58 in 2017, 111 in 2022). The Denial group had significantly longer approval times than the No Denial group in both 2017 (58.7 vs. 10.4 days; p=0.012) and 2022 (132.2 vs. 11.9 days; p<0.001). Among denied cases, mean approval time rose significantly from 2017 to 2022 (58.7 vs. 132.2 days; p=0.014); non-denied cases showed no change. Conclusions: Initial PA denial was associated with substantially prolonged approval times for outpatient orthopaedic surgery, and delays more than doubled from 2017 to 2022. These findings suggest the burden of PA appeals may be rising and underscore the need for larger multicenter studies to characterize insurer-related delays.