Medicare Advantage (MA) is, all too often, not advantageous to those who need it. Members routinely face obstacles that slow down the wound care they desperately need.
Prior authorization layers, repeated documentation requests, inconsistent coverage criteria, and long insurer review times can create delays that directly affect outcomes. These setbacks often halt procedures and therapies that are time-sensitive, including debridement, biologics, and advanced dressing options.
As a provider of care services, we see how these systemic barriers impact patients and why timely approval can be vital for recovery.
Prior Authorization as a Barrier in Clinical Wound Care
Patients and providers often expect that a Medicare Advantage plan will expedite access to treatments, yet many find that the approval pathway is significantly more restrictive than traditional Medicare.
Prior authorization is positioned as a utilization management tool, but for many, MA plans frequently apply criteria that are narrower than Medicare’s own policies. This can prevent patients from getting therapies that have strong clinical justification.
How Prior Authorization Creates Delays for Procedural Care
Even when a procedure is medically necessary, the review period can stretch days or even weeks. During that time, wounds continue to progress. For individuals who visit our advanced wound care centers, any delay risks increasing pain, infection risk, and overall healing time.
MA plans often slow down the process through:
• Requests for repeated chart notes
• Denials that require appeal even when criteria are met
• Requirements that patients “fail” simpler options first
• Limited approval windows that expire before treatment cycles finish
These roadblocks are especially problematic for therapies that must be performed within specific clinical timeframes.
Debridement Delays and Their Consequences
Debridement is one of the most frequent procedures needed for patients with chronic or non-healing wounds. It removes dead tissue, reduces bacterial load, and allows the wound bed to progress toward closure. When this process is postponed due to prior authorization demands, the wound environment often deteriorates quickly.
How MA Plans Can Delay Debridement
Many MA plans require prior authorization before certain types of debridement, especially surgical or enzymatic procedures. They may request extensive documentation demonstrating stalled healing, infection presence, or failure of conservative treatments.
For faster-progressing wounds, delays of even a few days can lead to:
• Increased bioburden
• Expansion of necrotic tissue
• Higher risk of cellulitis or systemic infection
• Pain escalation
• Setbacks that require more intensive future interventions
When our clinicians encounter authorization-related wait times, we often use interim therapies to stabilize the wound as much as possible.
However, these temporary approaches are not a substitute for the indicated procedure, and prolonged delays increase the risk that a patient will need more aggressive treatments later.
Biologic Applications and the Challenge of Narrow Coverage
Biologic products can significantly improve healing for complex or chronic wounds, especially when other methods have not produced adequate progress. They help stimulate tissue regeneration and support a healthier wound bed. Unfortunately, biologics are one of the most frequently delayed treatments under MA plans.
Why Biologics Are Delayed Under MA Policies
Because biologics are costly, MA plans often require extensive documentation, strict criteria, and multiple rounds of manual review. Some insurers demand proof of weeks, (or even months), of stalled healing before they will approve a biologic application.
Other plans require patients to undergo repeated measurements or photographic submissions before each application, slowing down the treatment cycle.
During these long review periods, wounds can worsen, especially for individuals with diabetes, compromised immunity, or vascular disease. When delayed, risks rise for:
• Chronic inflammation
• Thickened biofilm formation
• Deep tissue deterioration
• Reduced response once biologics are finally approved
We continue to advocate for more consistent and clinically appropriate criteria, but until national policy adjusts, these delays remain a common challenge.
Dressing Approvals That Slow Progress
Advanced dressings help maintain moisture balance, prevent infection, and protect fragile tissue. Yet some MA plans require prior authorization for certain dressing types, which can create interruptions in care.
How Dressing Delays Impact Treatment
Even brief disruptions in dressing access can lead to significant problems. When patients cannot receive the dressing type recommended by their clinician, they may experience:
• Increased drainage
• Skin maceration
• Dressing adherence that damages tissue
• Heightened discomfort
• Unnecessary clinic visits or emergency care
Our mobile team often encounters patients who run out of approved supplies while waiting for insurer review. When this occurs, we provide alternative short-term options, but the clinical goal is always to use the dressing that best supports that individual’s needs. Interruptions prolong healing and reduce patient comfort.
Real Consequences of Delayed Treatment
The cumulative effect of these authorization delays is substantial. Chronic wounds are dynamic and often deteriorate faster than insurers anticipate. When a necessary procedure or dressing is put on hold, patients may face:
• Higher infection risks
• Increased likelihood of hospitalization
• Greater need for systemic antibiotics
• Slower healing trajectories
• Lower quality of life
• More expensive long-term care
When a wound is left untreated or under-treated, the pathway to recovery threatens to become longer and more complex.
How Our Team Helps Patients Navigate These Challenges
Our clinicians recognize how much prior authorization can stand in the way of timely care. That is why we dedicate significant administrative and clinical support to helping patients move through these processes as efficiently as possible.
We coordinate with insurers, gather documentation, and expedite submissions to reduce unnecessary delays.
Steps We Take to Minimize Treatment Interruptions
To help patients move forward, we:
• Prepare and submit detailed clinical documentation on the patient’s behalf
• Provide insurer-requested information quickly to avoid processing gaps
• Advocate directly with MA medical reviewers when criteria are met
• Offer interim stabilization options for wounds experiencing delays
• Provide patient education that supports care continuity
• Work closely with caregivers to ensure proper at-home wound support
Because we also offer dermatology care, we are able to address underlying skin concerns that may complicate the healing process. This integrated approach helps create better long-term outcomes.
Supporting Patients Through a Holistic Wound Care Approach
When the system slows down treatment, the need for comprehensive support becomes even greater. That is why our care model emphasizes holistic wound care that goes beyond procedural interventions. We look at the patient’s full health profile, environmental factors, movement limitations, and comorbidities.
This expanded approach allows us to help patients maintain stability while waiting for authorization. It also gives our team more tools to reduce setbacks and improve comfort.
Our clinics and mobile services focus on:
• Thorough assessment
• Coordinated follow-up
• Preventive strategies that limit deterioration
• Evidence-based care plans
• Individualized support that matches the patient’s daily needs
When delays occur, we step in to strengthen every aspect of treatment we can control.
Helping Patients Receive Prompt Wound Care
We work every day to reduce barriers, improve access, and support patients through each stage of their wound care journey. Whether seen at one of our clinics or through our mobile services, patients receive dedicated care, advocacy, and attention from a team focused on achieving the best possible outcomes.