An approval should last as long as the treatment it covers. Consider a patient with type 1 diabetes who uses a continuous glucose monitor. Her condition is lifelong, and her device and supplies are the same each month. Every 6 months, her endocrinologist’s office sends the same documentation to her plan to renew the prior authorization, and the plan approves it. Nothing about her diagnosis or her need has changed. The approval lapses anyway, because it was written to last 6 months rather than as long as the treatment.
Multiply that by every stable patient on a long course of care and the result is a large share of prior authorization work that asks a question the plan already answered. The fix does not require new technology. It requires changing what an approval is tied to.
Renewals ask a question that was already answered
The first approval of a long-term treatment is a real decision. A clinician reviews the diagnosis against the criteria and decides whether the course of care meets them. A renewal for a patient whose situation has not changed repeats that decision with the same inputs. The answer is almost always the same.
The cost is not. Each renewal is a request a practice has to assemble and a plan has to review. In a December 2024 survey of 1,000 physicians by the American Medical Association, respondents reported completing an average of 39 prior authorizations a week and spending about 13 hours a week on them. Renewals of unchanged treatments are part of that count. When a renewal arrives late, or sits in a queue past the expiration date, the patient feels it as a gap in supplies or a postponed visit, not as an administrative detail.
Renewals carry a second risk that is easy to miss. A renewal can be denied for reasons that have nothing to do with the patient, such as a missing form or a fax that never arrived. The treatment stops while the office resubmits or appeals, and the eventual approval only restores what should never have lapsed.
Renewals also crowd out the reviews that matter. A nurse who spends the morning re-approving stable courses of care has less of the afternoon for the request that turns on a hard clinical question. We made a version of this argument last month, when we wrote that review effort should go where the uncertainty is.
The rules already point this way
Medicare Advantage made course-of-treatment approvals the rule starting in 2024. The regulation, at 42 CFR § 422.112(b)(8), sets the standard for enrollees in an active course of treatment.
The same provision requires coordinated care plans to give a new enrollee in active treatment a transition period of at least 90 days, during which the plan may not require prior authorization for that course of treatment. CMS described both requirements in its fact sheet on the final rule.
Other parts of the market are moving in the same direction. In June 2025, health plans committed that starting January 1, 2026, a new plan would honor existing prior authorizations for benefit-equivalent in-network services during a 90-day transition. Several states have written protections into law. According to a MultiState review of 2025 legislation, Montana passed a law requiring a new plan to honor prior approvals for at least 3 months after a person switches plans, and making approvals valid for 12 months for enrollees with chronic conditions. The National Conference of State Legislatures notes that in Mississippi, a prior authorization for a chronic condition is valid for 12 months or the length of treatment, whichever is less.
These protections share a principle. Once a plan has decided that a course of treatment is appropriate, the burden of reopening that decision should fall on a reason to reopen it, not on the calendar.
If nothing about the patient has changed, a renewal request asks a question the plan has already answered.
Re-review should follow change, not the calendar
Tying an approval to the course of treatment does not mean approving it forever. It means naming the conditions under which the plan will look again. Most of them can be seen in data a plan already has.
- A change in the treatment. A dose increase or a new indication is a new clinical question and deserves a new review.
- A change in the patient. A new diagnosis or signs that the treatment is no longer being used can signal that the original decision needs another look.
- A change in the evidence or the coverage rule. A new coverage determination or a revised guideline can change what the criteria require.
- A defined end to the course. Some treatments have a natural length, such as a 12-week course of therapy. An approval for that course should last 12 weeks, not 4.
Calendar renewals still have a place for a narrow set of services, such as high-cost therapies where periodic confirmation of response is part of the evidence base. For those, the renewal should ask only the question that matters, such as whether the treatment is still working, rather than requiring the original request to be rebuilt from scratch.
This approach has a failure mode that plans need to watch. An approval with no fixed end date can outlive the treatment it was meant for, so the triggers have to be monitored, not just written down. Claims and pharmacy fills are the usual signals, and each one should be checked against the open approval when it arrives.
What we build for
We build tools that health plans use in utilization review, and we think an approval should carry an end condition rather than an arbitrary end date. That means recording, at the time of the first decision, what the course of treatment is expected to be and what would prompt another look.
It also means treating a renewal of an unchanged treatment as the kind of request software can approve on its own. A machine can say yes. Only a person can say no. When the data shows a real change, such as a new dose or a new diagnosis, the request should go to a clinician with that change already highlighted, so the review starts where the question is. Either way, the record should show what was compared and why the request was routed the way it was.
The patient with the glucose monitor should hear from her plan when something about her care changes. Until then, her approval should simply keep working.