Heart Rhythm Society and Heart Rhythm advocates position statement: Prior authorization in cardiac electrophysiology: Evidence, policy, and reform.

Prior authorization (prior authorization) requirements imposed by Medicare Advantage (Medicare Advantage) and commercial insurers have evolved into a systematic barrier to guideline-indicated cardiac electrophysiology (electrophysiology) care, producing measurable patient harm, substantial administrative burden on physicians and allied professionals, and widening health care disparities.

This paper examines the financial architecture of the Medicare Advantage capitation model and the structural incentives it creates for denial, characterizes the root causes of the denial system, including third-party denial organizations, artificial intelligence-based algorithms, and opaque coverage criteria; reviews federal oversight findings from the Office of Inspector General and the Senate Permanent Subcommittee on Investigations, and analyzes procedure-specific denial patterns for catheter ablation of atrial fibrillation, implantable cardioverter-defibrillator therapy, left atrial appendage occlusion, and cardiac resynchronization therapy with defibrillation.