Robo Medicine

By Alexander Fernandez

Life News Today, Reporter

Doctors prescribe medications with the patient, not the population, in mind. Yet for millions of patients, that individualized judgment increasingly collides with insurance coverage systems where approval decisions are generated automatically, based on rules set by insurers and pharmacy benefit managers rather than by the treating physician. Each prescription reflects a complex assessment of medical history, current conditions, risk factors and the anticipated balance between benefit and harm. Medications that appear interchangeable on an insurer’s drug list often are not interchangeable in clinical practice, where differences in metabolism, medical history, prior treatment failures and side effects can determine outcomes.

The disconnect between individualized medical judgment and automated coverage decisions programmed around insurer policy sits at the center of a growing debate over how access to care is determined. “Medical decisions must be made by physicians and their patients without interference from unregulated and unsupervised AI technology,” American Medical Association (AMA) President Bruce A. Scott, M.D., said in a Feb. 24, 2025, AMA press release.

Those automated coverage decisions are enforced through management tools which stand between a prescription and the pharmacy counter. Prior authorization requirements, step therapy rules, quantity limits and preferred drug lists are embedded into insurer systems that evaluate prescriptions against preset policy criteria.

A Health Affairs policy analysis titled, “The AI Arms Race in Health Insurance Utilization Review” from 2026 found that 37% of insurers use or plan to use AI for prior authorization, 44% for claims adjudication, and 56% for other utilization management functions, showing that automated tools now play a routine role in coverage decisions.

In many cases, insurers and pharmacy benefit managers apply those rules automatically, approving, denying or redirecting prescriptions before any human review occurs. The result is that a treating physician’s documented clinical judgment can be overridden by software programmed to enforce policy criteria rather than evaluate the full context of an individual patient.

A gap opens when a doctor prescribes one treatment and insurer rules dictate another. Physicians prescribe based on a complete clinical picture that may include contraindications, drug interactions, age-related risks, pregnancy considerations, mental health history, or documented adverse reactions to similar medications. Coverage determinations, by contrast, often rely on diagnosis codes, limited clinical fields and preprogrammed criteria that do not capture those nuances. In public forums, patients describe being forced into substitutions despite documented treatment failures.

One Reddit user wrote that their insurer denied Humira after nearly three weeks of back-and-forth, writing, “I have been in contact with my doctor and health insurance company back and forth for almost 3 weeks trying to get updates on the status of the claim for the medicine (prior authorization requested by doctor) only to find out yesterday when I called the insurance that they are denying me the medication, because I haven't tried drugs X, Y, and fucking Z.” The Reddit user continued, “I have tried 7 different medications and none of them have worked and the insurance still has the audacity to dictate what I need for my health.”

Step therapy is one of the methods insurance companies use to require patients to try certain medications before they will cover the drug prescribed by a doctor. That requirement often triggers prior authorization, delaying treatment for days or weeks, during which conditions may worsen or patients may abandon care altogether. According to the AMA’s annual prior authorization survey, 78% of physicians said prior authorization often or sometimes leads patients to abandon a recommended course of treatment.

According to a 2025 national poll conducted by the PAN Foundation, 54% of commercially insured adults reported their health plan told them medications for a chronic or rare disease were no longer covered, a change respondents said caused delays and negative health effects. For individuals managing chronic illness, mental health conditions, pain, or complex medication regimens, even short interruptions can destabilize treatment plans that took months or years to refine.

In many cases, insurers reverse coverage decisions only after physicians intervene. According to the AMA, more than 80% of prior authorization denials result in partial or full approval after doctors submit additional clinical documentation or engage directly with insurer medical staff; an outcome indicates the original denial failed to reflect the patient’s clinical circumstances. By the time coverage is restored, patients experience harm, including unmanaged symptoms, adverse reactions to forced alternatives, and erosion of trust in the care process.

Insurers and pharmacy benefit managers control the decision rules, the automation that executes them, and the processes that determine how quickly a wrong decision gets corrected. The AMA’s data shows many denials collapse only after physicians push back, yet the delay still disrupts treatment for patients and slow physician decisions due to repeated documentation and negotiation with insurance companies. Until insurers explain how these rules are written, how automated decisions are made, and what happens when patients are harmed, the public has no clear way to understand who controls access to prescribed medicine.