APPLIES TO: Medicare Advantage · Medicaid · Marketplace plans

Medicare Advantage insurers turned down about one in eight standard prior authorization requests last year. When a patient or doctor appealed one of those denials, the insurer reversed itself two out of three times. [2]

Both numbers come from reports insurers had never been required to publish before this year, and I’ve been waiting a long time to see them. When two out of three appealed denials get reversed, I want to know how many of the rest were wrong too. But do the general population or even healthcare professionals know where to get these or what to do with these results?

If you read these reports together, they say something about what is really going on with prior authorizations. A large number of the first prior auth denials shouldn’t have been denied, and many of those are never appealed to even find out if they could overturn the denial. Had they submitted the appeal, many of those would have been approved. This tells me that the first denials are rarely right for patient care.

Under a federal rule (CMS-0057-F), Medicare Advantage plans, Medicaid managed care plans, and insurers on the federal marketplace had to post their 2025 prior authorization numbers on their own websites by March 31, 2026. [1] For those of you new to this space, a prior authorization is the approval some plans require before they’ll pay for a test or procedure or even a treatment. The reports basically show the approval and denial rates, how often denials were reversed on appeal, and how long decisions took.

Before this, a physician’s office knew its own denial numbers and an insurer knew its own stats. However, what we were missing was an ability for the public to compare one insurer with another. While this moves us in the right direction, the data is still hard to find, and hard to understand unless you are used to managing denials and appeals all day long.

KFF, a nonprofit health policy research group, pulled the reports from 14 of the largest insurers, covering about 71 million people. Standard requests were denied 12% of the time in Medicare Advantage, 14% in Medicaid managed care, and 18% in the marketplace. Within Medicare Advantage plans, the gap between different insurers was wide: 5% at Elevance and 17% at UnitedHealth Group. [2]

Then come the appeals. When a denial was appealed, it was overturned 67% of the time in Medicare Advantage, 47% in Medicaid managed care, and 43% in the marketplace. [2] What we don’t know is what documentation was needed to get the appeal approved and how that differs from the documentation submitted on the prior authorization request. So I don’t want to assume that this is just the payers denying for the sake of denying. However, it does show that most of the time, the physicians were practicing evidence-based care that was needed.

Very few denials ever get that second look. An earlier KFF analysis found that in 2024, only 11.5% of Medicare Advantage denials were appealed at all, and most of those were overturned. [3] For most denied requests, since they were never appealed, the denial ended up being the final answer for those patients, whether it was right or not.

As you can imagine, just publishing numbers isn’t the same as making them easy to read. Each insurer posts its own report on its own website, often split by contract or by state, in its own format. A policy research group called FREOPP rebuilt UnitedHealthcare’s Medicare Advantage numbers from its individual contract filings. The company’s public page showed 95.4% of requests approved, which works out to a denial rate of about 4.6%. Across all 63 of its contracts, weighted by how many requests each one handled, the denial rate was 12.9%. [4]

Both figures can be accurate, depending on how they are being counted. However, if the reports are hard to understand, how much does that really help the general population or employers when selecting plans?

The reports have other limitations. The prior auth rates are totals across everything a plan reviews, so you can’t tell whether the denials are related to imaging or surgery, and prescription drugs are left out entirely. [1] KFF also found that some other optional measures weren’t reported consistently between payers, making it impossible to compare those. [2]

None of this applies to employer plans, including the self-funded plans that cover most workers with job-based coverage. [1] If your coverage comes through work, there’s no report to look up.

So essentially, we are seeing a theme here as I dive into health plans and transparency around coverage. The essential health benefits rules and the state biomarker laws both reach individual, Medicaid, and Medicare plans and stop short of self-funded employer plans. People with the most common coverage keep getting the least information.

I also want to make sure I am telling this from both sides and trying to be fair. Some of the data from the payers does show useful information. For example, the median decision on a standard prior auth request took about one day, far faster than the 14 days the rules allowed. [2] Close to nine in ten Medicare Advantage prior auth requests were approved. And a reversed denial doesn’t always mean it was an inappropriate or wrong denial because an appeal often includes medical records that weren’t sent with the first request. Often, front desk staff or billing staff are filling out the first prior auth request, and when the denial comes in, the physician or clinical staff is getting involved to get the right information over. What this tells me is how difficult the prior auth process is, which makes it challenging to get the right answer up front.

I also believe that when two out of three appealed denials are reversed, and most denials are never appealed, a lot of patients are going without the care they would have gotten if someone had asked twice.

Physicians and practice leaders: look up the reports for the insurers your patients use most. A high overturn rate is a reason to appeal more often, not less.

Patients with Medicare Advantage, Medicaid, or a marketplace plan: if a prior authorization is denied, ask your doctor about an appeal before you treat the answer as final.

Employers: ask your plan for the same numbers for your own employees. Nothing requires it to give them to you, but you’re the customer.

“Last year, what share of prior authorization requests did my plan deny, and how many of those denials were overturned on appeal?”

The letters on your insurance card, HMO, PPO, EPO, or POS, sound like rules. Legally, they mostly aren’t. Next week I’ll explain what each one controls, and the one thing none of them tells you: which care needs your plan’s permission before it will pay.

If you’ve looked up your insurer’s report, reply and tell me what you found.

Gavari does not take money from health insurers or health plans. If an issue has a sponsor, it is labeled at the top.

This is general education about how health coverage works. It is not insurance, legal, or medical advice. I do not sell insurance or recommend plans.

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