Imagine a 54-year-old construction worker named Mike living with debilitating chronic lower back pain after years on the job. His doctor recommends a targeted epidural steroid injection and a short course of physical therapy combined with a non-opioid medication that has helped many patients in similar situations regain function and avoid surgery. But the insurance company says no. First, Mike must try cheaper generic pain pills that barely touch his pain and leave him groggy and nauseated. Then he has to wait weeks for approval of the injection. Meanwhile, his pain worsens, he misses more work, his family struggles financially, and he starts relying on stronger opioids just to get through the day. This is not a rare story. It happens constantly with pain management services because of prior authorization and step therapy. What were meant to control costs have created a bureaucratic nightmare that drives up total health care spending, delays effective relief, and leaves real people in unnecessary agony.

Doctors and their teams are drowning in the paperwork. On average, physicians and staff spend about 13 hours each week handling 39 prior authorization requests per doctor. That time adds up to thousands of dollars per physician in staff salaries alone, pulling everyone away from actual patient care and fueling burnout across the profession. Pain management clinics in particular dedicate entire teams just to chase approvals for injections, nerve blocks, imaging studies, physical therapy sessions, and non-opioid treatments. These processes do not even save money for the health care system as a whole. When effective pain care gets delayed or denied, patients often end up sicker, more disabled, and needing far more expensive interventions later as emergency room visits, long hospital stays, surgeries, or heavy opioid use with its own serious complications. Physicians regularly see patients deteriorate into chronic pain cycles, increased opioid dependence, lost productivity, and preventable complications. Studies show these delays lead to worse outcomes, higher overall costs, and many patients simply giving up on recommended treatments because the process takes too long.

Step therapy adds its own layer of unnecessary suffering. Often called “fail-first” policies, step therapy forces patients with chronic pain to try and fail on older, cheaper medications (often less effective drugs) before insurance will cover the safer, more targeted treatments their doctor prescribed. For people living with severe back pain, neuropathy, arthritis, or post-surgical pain, those extra weeks or months can mean prolonged suffering, reduced mobility, lost wages, depression, and sometimes permanent damage. Families face higher out-of-pocket costs, missed work, and a dramatically lower quality of life while patients wait to “prove” they need better care. Insurance denials make everything worse. In Medicare Advantage plans alone, millions of requests for pain management services are denied each year. While many denials are overturned on appeal, patients still endure weeks of waiting, worsening pain, and added stress. Lower-income families often face the heaviest burdens, with higher denial rates and tougher appeals. The result is more medical debt, untreated chronic pain, increased opioid misuse, and a growing loss of trust in the health care system.

The good news is that real reform is gaining real momentum. Lawmakers on both sides of the aisle recognize the problem. The Improving Seniors’ Timely Access to Care Act (H.R. 3514/S. 1816) has overwhelming bipartisan support, with hundreds of co-sponsors in Congress. This bill would streamline prior authorization in Medicare Advantage by requiring faster decisions, electronic systems that fit right into doctors’ electronic health records, clear and specific denial reasons, and annual reviews of requirements to make sure they are truly evidence-based. It also calls for greater transparency so everyone can see how often approvals and denials happen for pain procedures and services. Federal rules from the Centers for Medicare and Medicaid Services (CMS) are already kicking in. Starting in 2026, insurers must respond to urgent requests within 72 hours and standard ones within 7 days. They have to use modern electronic systems that make the process faster and less error-prone. A major Department of Health and Human Services (HHS) initiative announced in 2025 goes even further: Major insurers pledged to cut back on the number of services that need prior authorization by early 2026 (including many routine pain management procedures), honor approvals when patients switch plans, move toward real-time decisions by 2027, and make sure a real medical professional reviews every denial.

Many states and insurers are testing “gold card” programs that reward doctors who consistently make appropriate decisions by exempting them from prior authorization for routine pain services. Early results show big drops in delays without any spike in unnecessary care. Step therapy is getting attention too. The bipartisan Safe Step Act would create a clear, fast exception process, so patients with chronic pain do not have to fail on the wrong drug first. It sets tight timelines for decisions and lists commonsense reasons to skip the step, such as when a patient has already tried and failed certain medications or when delay could cause irreversible harm or opioid dependence. These changes are not about removing all oversight. They are about making oversight smarter, faster, and more humane. Pilot programs that have already simplified the process have cut denials dramatically while keeping costs in check and protecting patients. Evidence shows that reducing administrative waste, preventing pain escalation, and avoiding opioid over-reliance can actually lower the total bill for the health care system.

In the end, prior authorization and step therapy as they exist today waste billions, inflate overall spending through complications and rework, and keep patients from getting timely pain relief their doctors know they need. The human toll is heartbreaking: hardworking people like Mike trapped in constant pain, families stressed and struggling, doctors buried in paperwork, and lives unnecessarily disrupted. But with the reforms already moving forward, we have a real chance to replace rigid gatekeeping with trust, technology, and evidence-based care. Patients in pain deserve better. Doctors deserve better. And the entire system will work better when timely, appropriate pain management comes first. It is time to turn these promising proposals into reality and put people ahead of paperwork.

Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.

Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.

Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.