Commonwealth Fund October 8, 2024
TOPLINES
Medicare Advantage beneficiaries denied specific treatments or services can appeal, but the process can delay care and lead to health risks
Understanding the increase in appeals for Medicare Advantage denials and the decline in successful overturn rates is important for evaluating the program’s impact on beneficiary access to care
In 2021, Medicare Advantage (MA) plans denied 6 percent, or more than 2 million, prior authorization requests — that is, beneficiary requests for coverage of a specific service or treatment. An MA plan may determine that a service is not medically necessary, not a covered benefit, or that a more cost-effective service is available, among other reasons. When this happens, beneficiaries may file an internal appeal (referred to as a...
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