What Is Step Therapy?
Step therapy (also called fail-first or mandatory sequential therapy) requires that you try less expensive or less invasive treatments before insurers will approve more expensive or invasive options. For example, step therapy for back pain might require 12 weeks of physical therapy before authorizing MRI imaging. Step therapy for rheumatoid arthritis might require trying generic medications before approving biologic drugs.
Insurers argue step therapy reduces unnecessary spending and ensures patients receive appropriate initial treatment. However, it can delay necessary care and sometimes prevents access to superior treatments.
Common Step Therapy Requirements
Orthopedic Procedures: Typically require conservative treatment (physical therapy, medication, injections) before surgical authorization. The required duration and specific treatments vary by insurer.
Advanced Imaging: Often requires standard imaging (X-ray) before advanced imaging (MRI, CT) approval, even when advanced imaging is clinically indicated.
Specialty Medications: Many insurers require generic medications or older medications before approving newer, more expensive agents.
Appealing Step Therapy Denials
Step therapy can be appealed if: you have already completed the required step therapy and failed (the next level is now medically necessary), the required step is not appropriate for your condition (severe arthritis doesn't require 12 weeks PT before discussing surgery), or clinical evidence supports the higher-level treatment despite not completing step therapy.
Your healthcare provider should request a clinical exception to step therapy requirements if they believe the standard sequence is not appropriate for your specific situation. This request is often approved if well-documented clinically.
Step Therapy Laws
Some states have passed "step therapy" laws that require insurers to have reasonable processes for exceptions to step therapy when treatment failure or contraindication is documented. If your state has step therapy protections, reference them in your appeal.