Regulating the regulators: Ensuring ethical peer-to-peer insurance reviews

Physician peer-to-peer (P2P) review is the term for physician-level review of medical records commonly employed by health plans to determine whether to uphold a denial of coverage. P2P review was originally intended as a collaborative mechanism in the prior authorization process to promote evidence-based care while ensuring appropriate resource use. In contemporary practice, however, P2P review has evolved into an administrative checkpoint that may delay or restrict access to medically appropriate diagnostics and therapies. This is a growing concern, particularly relevant to dermatology amid rapid therapeutic innovation and increasingly complex disease management. The P2P reviewer's identity, specialty training, and decision-making criteria are frequently undisclosed, contributing to a process that limits accountability and undermines the physician-patient relationship, with serious ethical implications. Violations of autonomy, justice, and nonmaleficence may be further compounded by specialty discordance between treating physicians and payer-appointed reviewers. Greater transparency in reviewers' qualifications, specialties, and the rationale for decision making represents a critical step toward restoring the original intent of P2P review as a meaningful, ethical clinical dialog rather than a barrier to care. Aligning appropriate resource use while leaving bioethical principles intact is essential for protecting equitable access to dermatologic therapy and maintaining trust in the physician-patient relationship.