Somewhere right now, a doctor is deciding whether you really need that surgery, that medication, or that specialist visit. They've never met you. They've never listened to your heart or looked you in the eye. They're reviewing your case from a desk that might be hundreds of miles away, and they have about twelve minutes to make a call that could change your life.

This is utilization review—the process insurance companies use to decide whether your care is "medically necessary." It's one of the most consequential parts of modern healthcare, and most people don't know it exists until they get a denial letter. Understanding how it works is the first step toward protecting yourself.

When your doctor orders a procedure or prescribes a treatment, your insurance company often requires prior authorization—essentially, permission. A physician employed or contracted by the insurer reviews your medical records and decides whether the requested care meets their definition of medical necessity. This reviewer never examines you. They never talk to you. In many cases, they never even speak with your treating doctor.

These reviewers work from clinical guidelines—standardized criteria that reduce complex medical situations to checklists. Your doctor might write a detailed letter explaining why you need a particular treatment, but the reviewer is often looking for specific keywords and diagnostic codes. If your case doesn't fit neatly into a predefined box, the answer tends to be no. The nuance of your condition, the things your doctor noticed during an exam, the way your symptoms have progressed over months—all of that can get lost in translation.

Here's what makes this especially troubling: the reviewer may not even practice in the same specialty as your condition. A psychiatrist might review a cardiology case. An internist might weigh in on a complex orthopedic decision. Many states have started passing laws requiring specialty matching, but enforcement is inconsistent. The person holding the gate to your care may simply lack the context to understand what's behind it.

Takeaway

The doctor deciding whether you get care has never met you, may not share your doctor's specialty, and is working from a checklist—not a relationship. Medical decisions made without patient contact are fundamentally different from those made with it.

Insurance companies are businesses. Their revenue comes from premiums, and their costs come from paying for care. Every approved treatment is an expense. Every denial is savings. This doesn't mean individual reviewers are evil—most are licensed physicians who believe they're applying reasonable standards. But the system they work inside has a gravitational pull, and it pulls toward no.

Some insurers tie reviewer compensation to productivity metrics—how many cases they process per hour. When you're incentivized to move fast, complexity becomes an obstacle. Saying yes often requires more documentation, more justification, more time. Saying no is quicker. Former utilization review physicians have described cultures where high denial rates were implicitly rewarded, and where approving too many cases drew scrutiny from management. The pressure isn't always explicit, but it doesn't have to be. People learn what the organization values.

ProPublica, investigative journalists, and state regulators have documented cases where insurers used algorithms and automated systems to deny claims in bulk—sometimes without any physician review at all. In 2023, a major lawsuit revealed that one insurer's AI system was overriding physician reviewers, denying claims with a turnaround time that made meaningful review physically impossible. The structure doesn't require a villain. It just requires a system where the easiest path leads to denial.

Takeaway

You don't need a conspiracy to get bad outcomes—just a system where speed is rewarded, denial is cheaper, and the person affected has no seat at the table. Always ask: who benefits from this decision?

Here's the part the system hopes you won't learn: you have the right to appeal, and appeals work more often than you'd expect. Studies consistently show that when patients or their doctors appeal denied claims, a significant percentage get overturned—some estimates range from 40 to 60 percent for internal appeals. The denial isn't a final answer. It's an opening position.

Most insurance plans are required to offer at least two levels of appeal. The first is an internal appeal, where a different reviewer at the insurer re-examines your case. If that fails, you can usually request an external review—an independent physician outside the insurance company evaluates whether the denial was justified. External reviews are particularly powerful because the reviewer has no financial relationship with your insurer. For employer-sponsored plans governed by federal law, external review is a legal right. Many state-regulated plans offer similar protections.

The most important thing you can do is get your treating doctor involved. A strong appeal includes a detailed letter from your physician explaining why the treatment is necessary for you specifically—not just in general. Reference the clinical evidence. Cite the insurer's own coverage criteria and show how you meet them. Keep records of every communication. And know your deadlines—appeals have strict time limits. If the process feels overwhelming, patient advocacy organizations and state insurance departments can help you navigate it.

Takeaway

A denial is not a diagnosis—it's a business decision, and it can be reversed. The appeals process exists because the system knows its first answers are often wrong. Use it.

Healthcare systems are built from thousands of small design choices, and utilization review is one of the most consequential. A doctor who has never met you, working under time pressure and financial incentives that favor denial, can override the judgment of the physician who knows you best. That's not a bug—it's how the system was built.

But knowing this gives you something powerful: the ability to push back. Understand the process, involve your doctor, and exercise your appeal rights. The system counts on your silence. Don't give it that.