Insurance and Prior Authorization for Home Infusion Therapy

The clinical need for home IV therapy is one thing; getting it covered by insurance is another. The prior authorization process — the system by which insurance companies review and approve (or deny) coverage for specific treatments in advance — is one of the most frustrating barriers patients face when transitioning from hospital to home IV care.

This guide explains how prior authorization works, why delays happen, what you can do about it, and where to find financial help if coverage is denied or inadequate.

What Is Prior Authorization?

Prior authorization (PA), also called pre-authorization or pre-certification, is a requirement by insurance companies that certain medical treatments, medications, or services be reviewed and approved by the insurer before they are provided. It is the insurer’s mechanism for verifying clinical necessity before committing to pay.

For home infusion therapy, prior authorization is typically required for:

Home IV antibiotics (OPAT)
Home total parenteral nutrition (TPN)
Infused biologics and monoclonal antibodies
IVIG
Specialty IV medications
The home infusion nursing service itself
Durable medical equipment (IV pump, supplies)

Prior authorization is not a guarantee of payment. Even with prior authorization, claims can be denied after the fact based on medical records, billing codes, or other issues. Prior authorization is a condition of coverage being considered — not a promise.

How the Prior Authorization Process Works

Step 1: Physician order

Your physician writes an order for home infusion therapy. This order includes the medication, dose, frequency, and anticipated duration of therapy.

Step 2: Home infusion pharmacy or care coordinator submits PA request

The home infusion pharmacy or the hospital’s case manager submits a prior authorization request to your insurance company on your behalf. This request includes:

The clinical diagnosis (why you need the treatment)
The prescribed medication and dose
Clinical notes supporting the medical necessity of the treatment
Ordering physician information

Step 3: Insurance review

The insurance company reviews the request, typically within:

Standard review: 3–5 business days (varies by insurer and state law)
Urgent/expedited review: 24–72 hours (when the clinical situation is urgent)

The review may be performed by the insurer’s internal medical reviewers or outsourced to a utilization management company.

Step 4: Decision

The insurer responds with:

Approval: Coverage is granted; PA number is issued; therapy can proceed
Partial approval: Coverage for a shorter duration or reduced quantity is granted
Request for additional information: The insurer needs more clinical documentation before deciding
Denial: Coverage is refused; reason is provided; appeal rights are explained

Why Delays Happen — and What to Do

Delays in PA approval are extremely common and can be dangerous when IV therapy is medically urgent. Common reasons for delays and what helps:

Incomplete documentation: The most common reason. The insurer requires specific clinical information (e.g., documentation that oral antibiotics were tried first, specific lab results, imaging reports). Your physician’s office or the home infusion coordinator must gather and submit this.

What you can do: Ask your case manager or home infusion coordinator what information has been submitted and what the insurer is requesting. Offer to help obtain records or push your physician’s office to respond quickly.

Understaffed insurance review teams: Some insurers have lengthy queues.

What you can do: Ask whether an expedited review can be requested given clinical urgency. Insurers are typically required by law to respond to expedited requests within 24–72 hours.

Insurer requires peer-to-peer review: The insurer requests a physician-to-physician call between their medical reviewer and your physician.

What you can do: Ensure your physician’s office is aware of this requirement and promptly schedules the call.

If the delay is putting your health at risk: Tell your physician. They can escalate by contacting the insurance company’s medical director or by issuing a statement of medical urgency. Your state insurance commissioner’s office can also be contacted if an insurer is unlawfully delaying an urgent medical authorization.

If Your Claim Is Denied

A denial is not the end of the road. Insurance denials are frequently overturned on appeal. The appeal process:

Step 1: Understand the reason for denial

The denial letter must state the specific reason(s) for denial, the criteria used, and your appeal rights. Common denial reasons include:

“Not medically necessary” — the insurer does not agree the treatment is required
“Not covered under this plan” — the benefit is excluded from your plan
“Experimental/investigational” — the treatment is not recognized as standard of care
“Step therapy requirement not met” — the insurer requires you to try a less expensive treatment first
“Missing documentation” — required clinical information was not provided

Step 2: Internal appeal (first level)

File a formal appeal with your insurance company within the required timeframe (typically 30–180 days from the denial date — check your denial letter for your specific deadline). Include:

A letter explaining why the treatment is medically necessary, written by your physician
Supporting clinical documentation (lab results, imaging, specialist notes)
Published medical literature or clinical guidelines supporting the treatment if available
Your own statement as the patient (some insurers consider patient statements in appeals)

Step 3: Second-level internal appeal

If the first appeal is denied, most plans allow a second-level internal appeal with additional review.

Step 4: External independent review

After exhausting internal appeals (or in some cases concurrently), you have the right to an independent external review by a neutral medical reviewer not affiliated with your insurance company. This is a federal right under the ACA for most health plans. External reviews overturn internal denials approximately 40% of the time nationally.

Request external review from your state insurance commissioner’s office or through the process described in your denial letter.

Step 5: Additional options

State insurance commissioner complaint: If you believe the insurer is acting in bad faith or violating state insurance laws
Employee benefits complaint (for employer-sponsored plans): The US Department of Labor handles ERISA plan complaints
Patient advocacy organizations: Many disease-specific organizations have staff or resources to help with insurance appeals
Healthcare attorney: For significant, complex denials, a healthcare attorney with insurance expertise can sometimes achieve results through direct engagement with the insurer

Medication-Specific Coverage Issues

Home IV antibiotics (OPAT)

Most major insurers cover home IV antibiotics when medically necessary. Common barriers:

Requiring the patient to remain hospitalized rather than treating at home (counterintuitively, hospitalization sometimes costs the insurer less in specific situations)
Limiting the duration of coverage to less than the clinically necessary course

Home TPN

Coverage for home TPN requires clear documentation of a medical condition that prevents adequate nutrition through the gut. Insurers scrutinize this closely. Criteria typically include a specific qualifying diagnosis (short bowel syndrome, bowel obstruction, severe malabsorption) and documentation that enteral (tube feeding) has been tried or is not feasible.

Biologic infusions

Biologics are expensive and frequently require PA, step therapy (trying less expensive alternatives first), and sometimes specialty pharmacy distribution agreements. Your physician’s office typically handles this, but delays are common. Manufacturer patient assistance programs (see below) often bridge gaps.

Financial Assistance Resources

If your insurance does not cover home infusion therapy, coverage is inadequate, or you are uninsured, the following resources may help:

Manufacturer patient assistance programs

Most pharmaceutical manufacturers offer patient assistance programs (PAPs) that provide free or discounted medications to patients who cannot afford them. Income limits apply and vary by program. Contact the manufacturer of your specific medication directly or search at NeedyMeds (needymeds.org) or RxAssist (rxassist.org).

Manufacturer copay assistance / copay cards

For commercially insured patients who face high out-of-pocket costs, many manufacturers offer copay cards or assistance programs that reduce your out-of-pocket obligation. These are not available for patients on Medicare or Medicaid. Ask your specialty pharmacy or physician’s office.

Medicaid

If you meet income eligibility requirements, Medicaid covers home infusion therapy in most states. Apply through your state’s Medicaid office or healthcare.gov.

Medicare home infusion therapy benefit

Since 2021, Medicare Part B includes a professional services benefit for home infusion therapy for certain qualifying drugs. The drug itself may still be covered under Part D or not covered at all. Coverage is complex; ask your home infusion coordinator to review your specific Medicare coverage.

Hospital financial assistance / charity care

If you were hospitalized and are transitioning to home therapy, the hospital’s financial counselors can connect you with hospital-based financial assistance programs. These programs exist at virtually every nonprofit hospital.

Disease-specific foundations and nonprofits

Many disease-specific organizations provide grants or financial assistance for patients:

HealthWell Foundation (healthwellfoundation.org)
Patient Advocate Foundation (patientadvocate.org)
Patient Access Network Foundation (panfoundation.org)
Disease-specific organizations (cancer, IBD, and many others) often have financial assistance programs

Home infusion company assistance programs

Some home infusion companies have their own patient assistance programs or can adjust billing arrangements for uninsured or underinsured patients. Ask your home infusion coordinator directly.

Who Can Help You Navigate This

Hospital case manager / discharge planner: The first resource. They coordinate PA requests, know your insurance, and can help escalate urgent situations.

Home infusion coordinator: Your home infusion company employs people specifically to manage PA and billing. Use them.

Social worker: Hospital social workers can connect you with community resources, financial assistance programs, and patient advocates.

Patient navigator or nurse navigator: Common in oncology settings; helps patients navigate the healthcare system including insurance issues.

Your physician’s billing/prior auth staff: Physicians’ offices often have dedicated staff who manage PA requests. Ask your doctor’s office to ensure someone is actively managing your authorization.

This guide is for educational purposes and reflects general information about US insurance practices. Coverage rules, appeal rights, and assistance programs vary by state, insurer, and individual plan. For advice specific to your situation, consult your home infusion coordinator, social worker, or a patient advocate.