Insurer Influence on Benign Hysterectomy Claims: Trends in Prior Authorization and Denials

Study Objective

To assess the financial and demographic impact of prior authorization and denial practices for hysterectomy procedures at a large academic institution, with a focus on potential racial and socioeconomic disparities introduced by insurer policies.

Design

Retrospective cohort study.

Setting

Tertiary-care academic medical center.

Patients or Participants

All patients with submitted insurance claims for benign hysterectomy between October 2016 and February 2022 were identified. Claims were categorized as “denied” if they remained denied after all levels of appeal, and “approved” if the patient underwent a hysterectomy procedure during this period. The two groups were mutually exclusive. Gynecologic oncology cases and patients with a primary address outside of Massachusetts were excluded.

Interventions

Undergoing a hysterectomy procedure for benign indications or receiving a final denial for hysterectomy.

Measurements and Primary Results

Among 2,410 patients, 118 were denied and 2,292 approved. Denials were more common among patients with private insurance versus public (95.8% vs. 74.0%, p < 0.001). One commercial insurer (Insurer A) accounted for 55.9% of denials but only 11.1% of approvals, suggesting that denials were driven more by insurer policy than clinical or demographic factors. Insurers B and C accounted for 17 (14.4%) and 16 (13.6%) of the total denials, respectively. There were no statistically significant differences in denial rates based on race or Social Vulnerability Index (SVI) (p > 0.05), though Black patients were overrepresented among denied cases (19.5% vs. 15.6%). A map plotting denials across Massachusetts in relation to SVI revealed clustering in higher-vulnerability areas, particularly urban centers such as Boston and Brockton. While quantitative differences in SVI were not significant, spatial patterns raise concerns about disproportionate impact on vulnerable communities.

Conclusion

Prior authorization for benign hysterectomy adds limited clinical value while creating barriers to care. Denials were primarily influenced by insurer policies and disproportionately affected privately insured patients. Policy reform is needed to reduce administrative burden and promote equitable access.