Prior Authorization Denial Rates —
The Data Medicare Doesn't Want You to Miss
For the first time, CMS requires Medicare Advantage insurers to disclose how often they deny your care. Here's what they reported.
📋 What is Prior Authorization?
Before your Medicare Advantage plan pays for certain equipment, procedures, or medications, they may require “prior authorization” — advance approval that the care is medically necessary. Plans can and do deny these requests, even when your doctor says you need it.
- High denial rates mean more patients face delays or go without needed care.
- High overturn rates mean many denials were wrong — reversed when challenged.
- CMS now requires all MA plans to publicly disclose these rates under the 2024 Interoperability and Prior Authorization Rule.
| Rank | Carrier | Denial Rate | YoY Change | Total PA Requests | Requests/Member | Appeal Overturn |
|---|---|---|---|---|---|---|
| #1 |
HMO/PPO
|
✗ 12.8% | — | N/A | 3.20 | 82.0% |
|
For every 100 requests to UnitedHealthcare, 13 are denied. Of those denied, 82% are overturned on appeal — meaning the original denial was likely wrong. Denial Rate by Request Type
DME (Equipment)
15.2%
Inpatient Admission
14.1%
Specialist Referral
10.3%
Prescription Drugs
12.9%
Imaging (MRI/CT)
11.4%
PA Burden Score: 67.3/100 — Higher score = more administrative burden on patients and providers. |
||||||
| #2 |
HMO/PPO
|
✗ 12.3% | — | N/A | 3.10 | 82.0% |
|
For every 100 requests to Centene Corporation, 12 are denied. Of those denied, 82% are overturned on appeal — meaning the original denial was likely wrong. Denial Rate by Request Type
DME (Equipment)
14.8%
Inpatient Admission
13.7%
Specialist Referral
9.9%
Prescription Drugs
12.4%
Imaging (MRI/CT)
10.9%
PA Burden Score: 66.5/100 — Higher score = more administrative burden on patients and providers. |
||||||
| #3 |
HMO/PPO
|
✗ 11.9% | — | N/A | 2.90 | 80.0% |
|
For every 100 requests to Aetna (CVS Health), 12 are denied. Of those denied, 80% are overturned on appeal — meaning the original denial was likely wrong. Denial Rate by Request Type
DME (Equipment)
13.5%
Inpatient Admission
13.0%
Specialist Referral
9.4%
Prescription Drugs
11.8%
Imaging (MRI/CT)
10.5%
PA Burden Score: 60.8/100 — Higher score = more administrative burden on patients and providers. |
||||||
| #4 |
HMO/PPO
|
✗ 11.2% | — | 53,000,000 | 2.60 | 82.0% |
|
For every 100 requests to Industry Average (All MA Carriers), 11 are denied. Of those denied, 82% are overturned on appeal — meaning the original denial was likely wrong. Denial Rate by Request TypePA Burden Score: 56.3/100 — Higher score = more administrative burden on patients and providers. |
||||||
| #4 |
HMO/PPO
|
✗ 10.9% | — | N/A | 2.40 | 75.0% |
|
For every 100 requests to Kaiser Permanente, 11 are denied. Of those denied, 75% are overturned on appeal — meaning the original denial was likely wrong. Denial Rate by Request Type
DME (Equipment)
11.8%
Inpatient Admission
12.1%
Specialist Referral
8.7%
Prescription Drugs
10.2%
Imaging (MRI/CT)
9.3%
PA Burden Score: 52.2/100 — Higher score = more administrative burden on patients and providers. |
||||||
| #5 |
HMO/PPO
|
✓ 4.2% | — | N/A | 1.80 | 70.0% |
|
For every 100 requests to Elevance Health, 4 are denied. Of those denied, 70% are overturned on appeal — meaning the original denial was likely wrong. Denial Rate by Request Type
DME (Equipment)
5.1%
Inpatient Admission
4.8%
Specialist Referral
3.4%
Prescription Drugs
4.0%
Imaging (MRI/CT)
3.7%
PA Burden Score: 34.9/100 — Higher score = more administrative burden on patients and providers. |
||||||
⚡ Your Rights When a PA Request Is Denied
- Request an expedited appeal if waiting could seriously harm your health. Plans must respond within 72 hours.
- Ask your doctor to submit clinical notes — most successful appeals include additional documentation.
- File a complaint with CMS at 1-800-MEDICARE (1-800-633-4227) or Medicare.gov.
- For DME: your DME supplier can often help with the appeal — they deal with these plans daily.
- Use our free Appeal Coach → to build a CMS-compliant appeal letter in minutes.
Data from KFF 2023 Medicare Advantage Prior Authorization Report and CMS Annual PA Reports. National average denial rate: ~18%. Individual plan results vary by geography and benefit package. CMS source →