What the data shows
KFF published the first broad look at insurer prior authorization data on August 13, 2026, covering 2025. Medicare Advantage insurers denied 12% of standard prior authorization requests. Medicaid managed care insurers denied 14%. ACA marketplace insurers denied 18%.
When those denials were appealed, 67% were overturned in Medicare Advantage, 47% in Medicaid managed care, and 43% in the federally facilitated ACA marketplace. KFF also found that prior authorization denials are rarely appealed at all.
Sixty-seven percent
Sixty-seven percent. In Medicare Advantage, two out of every three denials that somebody bothered to fight got reversed. Not reversed because the medicine changed. Reversed because somebody pushed back.
Most denials are not medical judgments. They are paperwork problems. A missing note from the doctor, a code entered wrong, an authorization that was never filed. The letter reads like a verdict. It is closer to a rough draft.
Those overturn rates stay high partly because so few people appeal. The easy wins never get caught, because nobody goes looking for them. Right now the system works fine for the small number of people who treat a denial as the start of a conversation instead of the end of one.
Craig
What to do with a denial letter
- Read the denial letter for two things: the reason it gives, and the deadline. Both are printed on it.
- On Medicare Advantage, you have 65 days from the date on the notice to file an appeal. If waiting could seriously hurt your health, ask for a fast review and the plan owes you an answer in 72 hours.
- On ACA marketplace and employer plans, you generally have 180 days to file an internal appeal. If the plan says no again, you can request an outside review, and the insurer has to follow that decision.
- Call your doctor's office before you write anything. Most reversals come from the doctor sending the record that was missing in the first place.
- Filing an appeal is a right. A plan cannot cancel your coverage or raise your premium because you filed one.
Send me the denial letter and I will tell you what it actually says and what your deadline is. I will do that for anyone, client or not. When I am your agent of record, I do not stop at reading it. I can call the carrier, get the claim detail released to me, and work the appeal until it is finished. That is the part I would rather do than have you sit on hold for.
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