New prior authorization data sheds light on medicare advantage denials

As you navigate your healthcare options, particularly within Medicare Advantage (MA) plans, you may have encountered prior authorization requirements. This is when your insurance company needs to approve a medical service or medication before you can receive it. Recently, new regulations have been put in place to shed more light on these processes [Medicare Rights Center].

The Centers for Medicare & Medicaid Services (CMS) began requiring MA organizations to publicly report data related to prior authorizations earlier this year [Medicare Rights Center]. This data includes how often prior authorization is used, how many requests are denied, and how many denials are overturned on appeal [Medicare Rights Center]. It also covers the processing times for both standard and expedited requests [Medicare Rights Center].

Unveiling Insurer Practices

Prior to this mandate, the extent of prior authorization denials by MA plans was not readily available to the public. However, newly released KFF analysis of the initial public data reveals that MA plans denied at least one in eight standard prior authorization requests in 2025 [KFF]. For some health services, the denial rates were even higher [KFF]. These denials can lead to delays in care or beneficiaries not receiving services they believe are medically necessary [KFF].

The KFF analysis, which looked at 2025 data, found that among the largest MA organizations, denial rates for standard prior authorization requests ranged from 3% to 19% [KFF]. When beneficiaries appealed these denials, a significant portion — 82% — were overturned in favor of the patient [KFF]. This suggests that many initial denials may have been inappropriate, and highlights the importance of appealing a denial if you believe it is unwarranted [KFF].

Challenges for Consumers

While the goal of these new reporting requirements is to empower beneficiaries, challenges remain. The information is reported at a contract level, meaning data from several plans can be grouped together [Medicare Rights Center]. This makes it difficult for a potential enrollee to compare specific plans directly [Medicare Rights Center]. Furthermore, the data can be hard to locate on insurance company websites, sometimes hidden in unexpected places or even behind password protection [Medicare Rights Center].

CMS has acknowledged these issues and recently issued new guidance to improve how and where this information must be reported [Medicare Rights Center]. They also require MA organizations to post lists of services that need prior authorization [Medicare Rights Center]. However, making this information truly useful and accessible for the average consumer is an ongoing effort [Medicare Rights Center].

What This Means for You

As a Medicare Advantage enrollee or prospective enrollee, understanding prior authorization is crucial. If a service or medication requires prior authorization, ensure your doctor submits all necessary documentation promptly. If a request is denied, remember that you have the right to appeal. The high rate of overturned appeals suggests that persistence can often lead to a favorable outcome [KFF]. While the new data offers valuable insights into insurer practices, it still requires diligent effort from consumers to fully utilize for informed decision-making.