Medicare Advantage

Medicare Advantage Plans Made Nearly 53 Million Prior Authorization Decisions in 2024 — Here's What That Means for You

A new KFF analysis reveals the massive scale of prior authorization in Medicare Advantage, and why understanding the process can help you get the care you need faster.

February 10, 2026·By Senior Health Times Editorial Team·✓ Reviewed February 2026

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Key Takeaways

✓Medicare Advantage insurers issued nearly 53 million prior authorization determinations in 2024, according to a KFF analysis of CMS data.
✓The vast majority of prior authorization requests are approved, but denials — even a small percentage — affect millions of beneficiaries each year.
✓You have the right to appeal any prior authorization denial, and many appeals result in the original decision being reversed.
✓CMS has introduced new rules requiring faster prior authorization decisions and greater transparency from Medicare Advantage plans.
✓Understanding how prior authorization works before you need care can save you time, money, and stress.

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Medicare Advantage plans — the privately run alternative to Original Medicare — made nearly 53 million prior authorization determinations in 2024, according to a new analysis by KFF, a nonpartisan health policy research organization. That staggering number underscores just how central the prior authorization process has become in the day-to-day experience of the more than 33 million Americans enrolled in Medicare Advantage.

What Is Prior Authorization and Why Does It Matter?

Prior authorization is a requirement that your doctor or other health care provider get approval from your insurance plan before delivering certain services, procedures, medications, or equipment. The insurer reviews the request to determine whether the care is considered medically necessary under the plan's rules.

In theory, prior authorization is designed to prevent unnecessary or potentially harmful treatments and to control costs. In practice, it can create delays, paperwork burdens for physicians, and — in some cases — outright denials of care that patients and their doctors believe is needed.

For Medicare Advantage enrollees specifically, prior authorization requirements can differ significantly from what someone would experience under Original Medicare, which generally does not require prior authorization for most services.

The Scale of the Numbers: What 53 Million Determinations Really Means

To put the KFF figure in perspective: 53 million prior authorization determinations across roughly 33 million Medicare Advantage enrollees means that, on average, each enrollee was subject to more than one prior authorization review in 2024. Of course, the distribution is uneven — some beneficiaries, particularly those with serious or chronic illnesses, may face many more reviews, while healthier enrollees may face few or none.

The KFF analysis draws on data that Medicare Advantage plans are required to report to the Centers for Medicare & Medicaid Services (CMS). This reporting requirement itself is relatively recent, reflecting growing federal scrutiny of how prior authorization is being used across the industry.

Approvals vs. Denials: What the Data Shows

The good news is that the overwhelming majority of prior authorization requests are approved. Historically, CMS data has shown approval rates above 90 percent across Medicare Advantage plans. However, even a denial rate of just a few percent, applied to tens of millions of requests, translates into millions of beneficiaries who are told — at least initially — that their requested care will not be covered.

Denials can occur for a variety of reasons: the service may not be considered medically necessary under the plan's criteria, required documentation may be incomplete, or the request may involve a provider or facility outside the plan's network.

Your Right to Appeal a Denial

If your Medicare Advantage plan denies a prior authorization request, you have clear, federally protected rights to challenge that decision. The appeals process has multiple levels, and research has consistently shown that a meaningful share of denials are overturned on appeal — particularly when a physician provides additional supporting documentation.

How the Appeals Process Works

The first step is typically an internal appeal, sometimes called a redetermination, filed directly with your plan. If that is unsuccessful, you can escalate to an Independent Review Entity, then to an Administrative Law Judge, and ultimately to federal court if necessary. Time limits apply at each stage, so it is important to act promptly after receiving a denial notice.

For urgent or time-sensitive situations, you can request an expedited appeal, which requires the plan to respond within 72 hours rather than the standard 30-day window.

New Federal Rules Are Changing the Landscape

In response to widespread concerns about prior authorization delays and denials, CMS has implemented significant new requirements for Medicare Advantage plans in recent years.

What the New CMS Rules Require

Under rules that took effect in 2024 and 2026, Medicare Advantage plans are now required to make prior authorization decisions more quickly — within 72 hours for urgent requests and seven calendar days for standard requests. Plans must also provide specific, written reasons for any denial, making it easier for beneficiaries and their doctors to understand what additional information might lead to an approval on appeal.

Additionally, CMS has moved to require that prior authorization approvals remain valid for the duration of a course of treatment, preventing plans from requiring repeated re-authorization for ongoing care. Plans are also required to report prior authorization data publicly, which is what enabled the KFF analysis in the first place.

Practical Steps You Can Take Right Now

Knowing your rights and understanding the process before you need care is one of the most effective things you can do as a Medicare Advantage enrollee.

Before You Need Care

Review your plan's Evidence of Coverage document, which lists which services require prior authorization. Ask your doctor's office whether they are familiar with your plan's prior authorization requirements — many large practices have dedicated staff who handle these requests routinely. If you are considering switching plans during the Annual Enrollment Period, compare prior authorization requirements as part of your evaluation.

If You Receive a Denial

Do not simply accept a denial as the final word. Ask your doctor to submit a letter of medical necessity with your appeal. Keep copies of all correspondence and note the dates of every interaction with your plan. Consider contacting your State Health Insurance Assistance Program (SHIP), which provides free, unbiased counseling to Medicare beneficiaries — including help navigating appeals.

The Bigger Picture: Ongoing Policy Debate

The sheer volume of prior authorization activity in Medicare Advantage has drawn attention from Congress, patient advocacy groups, and medical associations alike. Legislation aimed at further reforming prior authorization practices has been introduced in recent sessions of Congress, reflecting bipartisan concern about the burden these requirements place on patients and providers.

For now, the most important thing for Medicare Advantage enrollees to understand is that prior authorization is a normal — if sometimes frustrating — part of how these plans operate, and that the system includes meaningful protections designed to ensure you can access the care your doctor recommends.

Sources & Further Reading

Frequently Asked Questions

What is prior authorization in Medicare Advantage?

Prior authorization is a process where your Medicare Advantage plan must approve certain medical services, procedures, or medications before you receive them. Your doctor submits a request, and the plan reviews whether the care meets its medical necessity criteria. Most requests are approved, but denials can be appealed.

How long does Medicare Advantage prior authorization take?

Under current CMS rules, Medicare Advantage plans must decide standard prior authorization requests within seven calendar days. For urgent or time-sensitive situations, plans must respond within 72 hours. If your plan misses these deadlines, you have the right to escalate your request through the appeals process.

Can a Medicare Advantage plan deny my prior authorization request?

Yes, plans can deny requests if they determine the service does not meet their medical necessity criteria or if required documentation is incomplete. However, you have a federally protected right to appeal any denial. Many denials are reversed on appeal, especially when your doctor provides additional supporting medical documentation.

Does Original Medicare require prior authorization?

Original Medicare generally does not require prior authorization for most covered services, which is a key difference from Medicare Advantage. Some exceptions exist, such as certain inpatient hospital stays or specific equipment. If avoiding prior authorization is a priority, comparing Original Medicare and Medicare Advantage plans during enrollment is worthwhile.

How do I appeal a Medicare Advantage prior authorization denial?

Start by filing an internal appeal — called a redetermination — directly with your plan, ideally with a letter of medical necessity from your doctor. If denied again, escalate to an Independent Review Entity. Act quickly, as time limits apply. Your local SHIP counselor can guide you through the process for free.

Are Medicare Advantage plans required to disclose their prior authorization rules?

Yes. Medicare Advantage plans must publish their prior authorization requirements in their Evidence of Coverage document, which enrollees receive annually. CMS also requires plans to report prior authorization data publicly. You can review your plan's specific requirements on Medicare.gov or by calling your plan directly.

Editorial Standards

This article was written by the Senior Health Times editorial team and is intended for informational purposes only. It does not constitute financial, legal, or medical advice. Coverage details and costs vary by plan, carrier, and state. Always verify information with official sources including Medicare.gov and your state insurance commissioner.

prior authorizationmedicare-advantageMedicare Advantage denialsMedicare appeals processCMS prior authorization rulesMedicare Advantage utilization managementsenior health insurance rights

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