Full Breakdown
Medicare Advantage Prior Authorization Denials Reach Record Levels
6/11/2026, 9:14:25 PM
Context: Prior Authorization in Medicare Advantage
Medicare Advantage delivers Medicare benefits through private insurers that receive a fixed per-member payment from the federal government. To curb costs, plans often require prior authorization before covering post-acute services such as long-term acute care, inpatient rehabilitation, or skilled-nursing facility stays.
Surge in Denials for Post-Acute Care
A June 2024 report from the HHS Office of the Inspector-General examined prior-authorization requests submitted in June 2024 by 19 Medicare Advantage groups. The analysis found denial rates for long-term acute care, inpatient rehabilitation, and skilled-nursing facility admissions ranged from 8 % to 80 % across insurers. UnitedHealthcare, CVS Health (Aetna) and Humana exhibited the highest denial percentages, in some cases rejecting more than 70 % of requests. Approximately 20 million beneficiaries are enrolled with these three for-profit plans.
Data Snapshot
- Denial rates: 8 %–80 % by insurer for long-term acute, rehab, or SNF requests.
- Appeal reversal: 95 % of denied SNF requests were overturned after formal appeal.
- Cost of appeals: $31 billion annually in paperwork and administrative burden.
- Average service cost: long-term acute stay $49,000; inpatient rehab $24,000 (2023).
Official Statements & Responses
The inspector-general’s office urged CMS to collect regular prior-authorization data and probe the wide variation in denial rates. Health Secretary Robert F. Kennedy Jr. pledged reforms and cited insurer commitments to streamline pre-approval rules. AHIP reported an 11 % reduction in prior-authorization requirements for services such as diagnostic imaging and outpatient surgery. UnitedHealthcare announced removal of two-thirds of pediatric authorization requirements, while Aetna said it reviews requests promptly and offers a clear appeals process.
Criticism & Opposition
Health-policy scholars argue the data reveal a profit-driven bias. Miranda Yaver of the University of Pittsburgh called the denial rates “staggering” and warned that decisions appear driven by profit rather than medical necessity. Meredith Freed of KFF noted that provider-side documentation errors cannot fully explain the unusually high denial percentages, labeling the pattern “inappropriate.” The report also found for-profit insurers more likely than nonprofit plans to deny prior-authorization requests.
Verbatim Quotes
- “These denial rates are quite staggering,” — Miranda Yaver, assistant professor of health policy and management, University of Pittsburgh
- “The range of denial rates from 8% all the way up to 80% by company for long-term care, that’s a pretty shocking variation,” — Erin Bliss, assistant inspector general, HHS
- “We’re looking at an extremely high overturn rate,” — Rosemary Bartholomew, lead author, HHS inspector-general reports
- “We review requests promptly, offer a clear appeals process, and are leading the way for continuous patient-centered improvements.” — Aetna spokesperson (CVS Health)
What’s Next
Secretary Kennedy’s office plans to impose stricter penalties on insurers that repeatedly deny care and to require CMS to expand prior-authorization data reporting. Lawmakers are drafting legislation that would levy financial sanctions on entities with high overturn rates after appeal.
