I’m sharing an actual recent peer-to-peer call that shows what physicians and patients face when trying to get a surgery approved. This call felt as absurd as it sounds.
— Elisabeth Potter MD (@EPotterMD) July 11, 2025
The peer-to-peer call was to advocate for surgery to prevent and treat lymphedema for a patient with breast… pic.twitter.com/SJz6ToWN8u
The Frustration of Peer-to-Peer Calls
Dr. Elisabeth Potter, MD (@EPotterMD), recently shared a frustrating experience on X about a peer-to-peer (P2P) prior authorization call. This was for lymphovenous bypass (LVB) surgery, revealing the breast cancer treatment challenges faced by patients. This procedure aims to prevent lymphedema in a high-risk breast cancer patient. Yet, the insurance company assigned an ophthalmologist specializing in oculoplastic surgery and a plastic surgeon focused on cosmetics—neither familiar with LVB. A 2024 American Medical Association (AMA) report confirms this issue. It notes that over 90% of physicians find P2P reviewers often lack relevant expertise, exacerbating breast cancer treatment challenges.
Worse, the insurance doctors withheld their names and license numbers, eroding transparency. United Healthcare had already decided to deny the procedure. This made the P2P call a formality rather than a clinical discussion. For breast cancer patients, these breast cancer treatment challenges due to delays heighten lymphedema risks, a condition that harms quality of life.
Systemic Flaws in Prior Authorization
Dr. Potter’s experience reflects broader issues in oncology. Prior authorization delays and denials worsen patient outcomes, as a 2023 Journal of the American Medical Association (JAMA) study shows. These delays also raise healthcare costs due to complications and frustrate oncologists. For patients at risk of lymphedema—a condition caused by lymph fluid buildup—timely LVB surgery is critical. It is endorsed by Memorial Sloan Kettering Cancer Center. Yet, insurance policies often override medical necessity, leaving patients vulnerable to breast cancer treatment challenges.
Impact on Oncologists and Patients
Board Certified Plastic Surgeon like Dr. Potter face a grueling cycle of advocating for patients while navigating an opaque system. The 2024 AMA report highlights that P2P calls rarely reverse denials. This wastes time better spent on care. For patients, denials mean delayed treatment, higher costs, and worse health. A 2024 AMA survey found 79% of physicians report patients paying out of pocket due to prior authorization issues. This is a heavy burden showcasing breast cancer treatment challenges.
Reforming Prior Authorization in Oncology
Dr. Potter’s story signals an urgent need to reform prior authorization, especially in oncology. Qualified physicians, not insurance policies, should drive medical decisions. P2P calls must involve true peers for meaningful dialogue. Addressing breast cancer treatment challenges requires oncologists to push for change. They can join forces with groups like the AMA, share experiences, and support legislative reform. The AMA’s 2018 “Consensus Statement on Improving the Prior Authorization Process” offers a clear path forward. By fixing inefficiencies and boosting transparency, we can empower oncologists to deliver better care.
FAQ
Why are peer-to-peer prior authorization calls often ineffective?
P2P calls fail because reviewers often lack relevant expertise. Also, decisions follow insurance policies, not clinical needs, as noted in the 2024 AMA report.
How can oncologists advocate for prior authorization reform?
Oncologists can collaborate with organizations like the AMA, share their stories, and back legislative efforts. The AMA’s 2018 Consensus Statement provides actionable guidance.