Updated November 2026. Prior authorization is the advance approval a health plan requires before it will pay for certain care, from MRIs and surgeries to nursing home stays and brand-name drugs. Insurers say it prevents unnecessary care and controls costs. Physicians say it delays treatment and harms patients. This report card collects the hard numbers now available from federal auditors, state regulators, physician surveys and the insurers themselves.
Key Findings
- Patients are harmed. 26% of physicians say prior authorization has led to a serious adverse event for a patient in their care, and 20% say it has led to a hospitalization (AMA 2025 survey).
- Paperwork is heavy. Physicians and their staff spend 13 hours a week on prior authorizations (AMA).
- Post-acute care is denied most. In June 2024, Medicare Advantage plans denied 65.3% of requests for long-term care hospital stays and 54.2% for inpatient rehabilitation (HHS Office of Inspector General).
- Appeals usually win in Medicare Advantage. Plans reversed 95% of appealed skilled nursing facility denials, but only 18% of denials were appealed (OIG).
- State data is arriving. Massachusetts carriers received 1.58 million prior authorization requests in 2024, up 13.3% in a year; Hawaii insurers denied 11.6% of requests in 2025.
What Physicians Report
The American Medical Association (AMA) surveyed 1,000 practicing physicians in December 2025. The AMA is a physician advocacy organization and supports prior authorization reform, so its survey reflects the physician side of the debate.
| Measure | Result |
|---|---|
| Physicians reporting a serious adverse event for a patient | 26% |
| Physicians reporting prior authorization led to a hospitalization | 20% |
| Physicians reporting disability, permanent damage or death | 8% |
| Weekly hours physicians and staff spend on prior authorization | 13 |
| Physicians who say prior authorization increases burnout | 94% |
| Physicians who say denials have increased over five years | 74% |
| Physicians concerned insurers’ AI use will increase denials | 60% |
Source: 2025 AMA Prior Authorization Physician Survey.
Medicare Advantage Denials for Post-Acute Care
Medicare Advantage is the private-plan alternative to Original Medicare. Original Medicare rarely requires prior authorization; Medicare Advantage plans use it widely. In 2026, the HHS Office of Inspector General (OIG) published two data briefs on prior authorization decisions made by 19 Medicare Advantage organizations in June 2024.
| Type of care | Requests denied |
|---|---|
| Long-term care hospital admission | 65.3% (2,108 of 3,230) |
| Inpatient rehabilitation facility admission | 54.2% (10,512 of 19,379) |
| Skilled nursing facility admission | 12% (range 0.4% to 23% by plan) |
| Skilled nursing care for current nursing home residents | 40%, versus 11% for other enrollees |
The three largest Medicare Advantage organizations denied long-term care hospital requests at some of the highest rates: CVS Health (Aetna) 79.6%, Humana 72.3% and UnitedHealth Group 70.9% (OIG, OEI-09-24-00330). For skilled nursing facility admissions, only 18% of denials were appealed, and plans reversed 95% of those appeals. naviHealth, a UnitedHealth Group subsidiary, handled half of all skilled nursing requests in the sample and saw 97% of its appealed denials overturned (OIG, OEI-09-24-00331).
An earlier OIG review found that 13% of prior authorization requests Medicare Advantage plans denied met Medicare coverage rules and would likely have been approved under Original Medicare (OIG, 2022). For plan choices, see our Medicare hub.
Prior Authorization Data From the States
A growing number of states now require insurers to report prior authorization volumes and outcomes. The first reports show how much the numbers vary by market and by type of care.
| State | Year | Requests | Result | Source |
|---|---|---|---|---|
| Massachusetts | 2024 | 1,578,924 (up 13.3%) | 86.2% approved; lab and pathology approvals fell to 64.6% | Massachusetts Division of Insurance |
| Hawaii | 2025 | 126,518 | 11.6% denied; Medicaid plans 14.2%, commercial 10.0%, Medicare 10.1% | Hawaii State Health Planning and Development Agency (preliminary) |
Hawaii’s report is preliminary and does not yet include data for two major carriers, HMSA and HMAA. Massachusetts figures were reported by carriers and not independently verified by the state.
Insurers Now Publish Their Own Prior Authorization Numbers
A federal rule issued by the Centers for Medicare & Medicaid Services (CMS), the Interoperability and Prior Authorization Final Rule (CMS-0057-F), requires Medicare Advantage plans, Medicaid and CHIP programs and HealthCare.gov insurers to post prior authorization metrics on their websites each year, starting March 31, 2026. The same rule requires decisions within 72 hours for urgent requests and seven calendar days for standard requests, beginning in 2026.
The reports are new and hard to find, but they are revealing. University of Utah Health Plans, for example, reported that its individual plan denied 19.81% of standard prior authorization items in 2025 and reversed 3.6% of standard denials on appeal (University of Utah Health Plans). To find your insurer’s report, search its website for “prior authorization metrics” or “CMS-0057-F.”
What To Do When Prior Authorization Is Denied
- Ask your doctor’s office to request a peer-to-peer review, a call between your doctor and the insurer’s medical reviewer.
- Request the denial in writing, with the specific clinical criteria the insurer used.
- File an appeal. In Medicare Advantage, most appealed post-acute denials in OIG’s sample were reversed.
- Ask for an expedited (fast) appeal if waiting could seriously harm your health.
- Contact your state insurance department or, for Medicare, 1-800-MEDICARE for help.
Claim denials after care is delivered are a separate problem; see our Health Insurance Claim Denial Rates by Insurer report. For policy updates, follow our Healthcare Policy and Law hub.
Sources
American Medical Association, 2025 Prior Authorization Physician Survey; HHS Office of Inspector General data briefs OEI-09-24-00330 and OEI-09-24-00331 (June 2026) and OEI-09-18-00260 (2022); Massachusetts Division of Insurance examination report (January 2026); Hawaii State Health Planning and Development Agency 2025 prior authorization report; University of Utah Health Plans CY2025 prior authorization compliance report; CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).