05/03/2026
A 47 year old woman asked for an MRI. By the time her insurance company let her have one, she had a sarcoma in her hip, and it was too late to save her leg.
Her doctor had already done the X-ray. He had already examined her. He had already sent her for physical therapy, the six weeks the insurance company's own published criteria said she needed to do before an MRI was on the table. There was no improvement. He told her she needed the scan.
The insurance company said it was not medically necessary, until she finished six weeks of physical therapy. She had finished it. They had paid for it. He appealed.
It took 38 days for the insurance company to reverse itself.
When she finally got the MRI, the cancer was already advanced. The doctors at the hospital told her that if she had come a month sooner, they could have treated it with chemotherapy alone. Instead, they amputated her leg, her hip, and her pelvis. She died two years later.
Her family sued. The federal judge who heard the case called it tragic, then threw it out, because no law in New York holds an insurance company accountable when it gives medical advice that turns out to be wrong. Doctors are accountable. Nurses are accountable. Hospitals are accountable. Insurance companies are not.
By law, the person reviewing a prior authorization denial is supposed to be a doctor in the relevant specialty. The federal inspector general found that very often, they are not. A pediatrician can deny a radiology request. A reviewer with no oncology background can decide a hip MRI is not medically necessary. The criteria the insurer publishes are not always the criteria the insurer follows.
Attorney Steve Cohen argued this case before the Second Circuit Court of Appeals. The American Medical Association, the New York State medical society, and the Vermont and Connecticut medical societies all filed friend of the court briefs supporting the family. The argument was simple. If you give medical advice, you are accountable for it.
This is not just a story about one woman. The American Medical Association has surveyed physicians for years. The overwhelming majority say prior authorization has caused real harm to their patients. Many spend 10, 15, 20 hours a week of staff time chasing approvals and appealing denials.
Send this to anyone who has ever been told no by their insurance company and wondered who actually decided.
Listen to the full conversation on The Podcast by KevinMD. Link in the comments.
What is the worst insurance denial you or someone you love has ever lived through?
