Transparency Gaps in Prior Authorization Denials and Their Impact on Dermatologic Care

“When they don't have information about what the covered alternatives are, it ultimately leaves us guessing, and this is inefficient for us, our staff, and it creates delays for the patients to get on treatment to help them get better,” said John Barbieri, MD, MBA, in a recent interview.

Barbieri, a dermatologist and director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital in Boston, Massachusetts, and an associate professor of dermatology at Harvard Medical School in Cambridge, recently co-authored a paper, “Prior Authorization Denials Lack Transparency and Accountability,” published in the Journal of the American Academy of Dermatology.¹

Some of the key findings of the study include:

• 75% of dermatology prior authorization (PA) denial letters did not identify a decision maker. Only 7% listed the full name of the reviewer.
• 41% of denial letters provided no information about step therapy or covered alternatives, even though the stated goal of step therapy is to help ensure appropriate care.
• Among appeal denials, only 31% engaged with the prescribing provider's arguments; the majority simply restated the original step-therapy criteria.

In his interview, Barbieri reviewed new findings on transparency gaps within prior PA denial letters and how these deficiencies affect timely dermatologic care.

Barbieri et al analyzed 100 consecutive denial letters from their health system to formally assess longstanding concerns about unclear reviewer authorship, poor documentation of step therapy requirements, and inadequate engagement with clinical arguments during appeals.

The evaluation revealed that “about three quarters, 75% of the denial letters, didn't include any real information about the decision maker”, frequently listing only initials or identification numbers. Barbieri emphasized that this absence of identifiable reviewers raises fundamental questions about accountability, particularly when payers “are ultimately deciding what treatments that patient can or cannot use.”

The study also found that “41% of letters didn't include really any information about what the covered alternatives were, ”creating substantial barriers for clinicians attempting to secure access to biologics, JAK inhibitors, and other advanced therapies. As Barbieri explained, when alternative options are not clearly outlined, “it ultimately leaves us guessing,” heightening inefficiencies, delaying treatment, and increasing the risk of complications. He noted prior data from the University of Pennsylvania showing that prolonged authorization timelines have, in some cases, contributed to hospitalizations for patients with connective tissue disease awaiting appropriate therapy.²

Appeal letters demonstrated another concerning trend: “in about 31% of them, there was no clear engagement with any of the arguments being made by the prescriber.” Barbieri described this as particularly troubling, noting that many peer-to-peer discussions now feel perfunctory, with reviewers who “have no willingness to engage in any sort of discussion about evidence or appropriate treatments” and who simply reiterate initial PA criteria. This approach, he said, results in further delays and forces clinicians toward complex third-party appeals with low success rates.

Barbieri urged colleagues to continue advocating for “common sense prior authorization reforms,” including transparent reviewer identification, standardized disclosure of covered alternatives, and genuine engagement with prescriber rationale. He emphasized the need for continued research to identify where current systems fail patients and to evaluate whether peer-to-peer processes function as meaningful clinical dialogues or merely procedural checkpoints that impede timely care.

References

1. Ershadi S, Greenberg ABW, Katini S, Barbieri JS, Cohen JM. Prior authorization denials lack transparency and accountability. J Am Acad Dermatol. 2025 Nov 3:S0190-9622(25)03140-8. doi: 10.1016/j.jaad.2025.10.140
2. Bernstein JA, Gadde D, Yassin M, et al. The impact of prior authorization on clinical practice and patient care outcomes: a work group report of the AAAAI Prior Authorization Task Force. J Allergy Clin Immunol Pract. 2024 Jul;12(7):1719-1726. doi: 10.1016/j.jaip.2024.01.051