Federal investigators are reviewing how Medicare Advantage plans use prior authorization and step therapy for Part B drugs. Here is what the review covers, what the national denial and appeal numbers actually say, and the steps that can help if your own care is delayed or denied.
Medicare Advantage Denials Face New Federal Review — 80% Reversed on Appeal
Medicare Advantage Prior Authorization Is Under Federal Review
More than 52 million Medicare Advantage prior authorization decisions were made in a single year. About 4.1 million of them were denied in full or in part.
But here is the number that changes the story. When patients or providers appealed those denials, more than 80 percent were overturned.
Now federal investigators are taking a closer look at one especially sensitive area: drugs covered under Medicare Part B.
What the New Review Covers
The review was announced by the Department of Health and Human Services Office of Inspector General. It focuses on how selected Medicare Advantage organizations use prior authorization and step therapy for Part B drugs.
These are often medications given in a medical setting, including certain injections, infusions, and biological products.
Investigators are examining selected cases to see whether plan decisions followed Medicare requirements, matched clinical guidelines, and avoided unnecessary delays.
What This Review Does Not Mean
This does not mean prior authorization has been banned. It does not change your coverage today.
It is also not a finding that every plan broke the rules. The review is active, which means questions are being asked, not that conclusions have been reached.
What Step Therapy Actually Is
A simple way to understand step therapy is the phrase “try this first.” A plan may require a patient to begin with its preferred drug before covering a different one.
Since 2019, Medicare Advantage plans have been allowed to use this approach for certain Part B drugs. Federal officials originally said it could encourage competition, help plans negotiate lower costs, and move patients toward less expensive treatments when those options are clinically appropriate.
That goal can make sense. Suppose two infused medicines treat the same condition, and a lower-cost biosimilar is likely to work just as well for a new patient. Trying that option first may save money for Medicare, the plan, and the patient.
But the same rule becomes a problem if the first drug is unsuitable for that person’s medical history, or if extra paperwork postpones treatment for a serious illness.
The Concern Investigators Are Testing
The Office of Inspector General says patient and provider groups have raised concerns that some plan requirements may not follow program rules or clinical guidance, and may contribute to worse outcomes through administrative delay.
Those are concerns being investigated, not conclusions that have already been proven.
Why the Scale Matters
Medicare Advantage now covers more than half of eligible Medicare beneficiaries. In 2026, about 35.2 million people, or 55 percent of beneficiaries with both Part A and Part B, are enrolled in these private plans.
Nearly all Medicare Advantage enrollees are in plans that require prior authorization for at least some care. So a rule change or a pattern of delay does not affect a small corner of the program. It reaches tens of millions of people.
The Numbers Behind the Headline
In 2024, insurers processed 52.8 million prior authorization determinations. They fully approved 48.7 million, so more than nine out of ten requests received a favorable answer.
The remaining 4.1 million, or 7.7 percent, were denied fully or partially. Only 11.5 percent of those denials were appealed, but 80.7 percent of the appeals were overturned in full or in part.
That reversal rate does not prove that four out of five initial denials were improper. An appeal may include medical records or clarification that the plan did not have the first time.
Still, it raises a fair question. Could some care have been approved sooner, before a patient and a medical office had to spend time challenging the decision?
How This Compares to Original Medicare
Original Medicare uses prior authorization on a much smaller set of services. It completed a little more than 628,000 reviews in fiscal 2024, and about 22.9 percent were denied.
That percentage is higher than the Medicare Advantage denial rate, but the two figures are not an apples-to-apples comparison. The programs review very different mixes of care, and Medicare Advantage requires authorization far more broadly.
One system has a higher denial percentage in a narrow pool. The other makes tens of millions more decisions. If you are weighing the two, our guide to Medicare Advantage pros and cons walks through the wider trade-offs.
Your Experience Depends on Your Plan
Experiences vary by insurer. Some plans ask for more authorizations per enrollee, while others deny a larger share of the requests they receive.
So two people with similar medical needs may face different administrative paths simply because they chose different plans.
That can mean the difference between a treatment beginning on schedule and a family spending days gathering records, making calls, and watching an appeal deadline.
This Is Not the First Warning Sign
In 2022, the inspector general reviewed samples from 15 large Medicare Advantage organizations. It found that 13 percent of sampled prior authorization denials met Medicare coverage rules and likely would have been approved under Original Medicare.
Reviewers found examples where plans used extra clinical criteria, or said documentation was insufficient even though the medical record supported the request.
What the Rules Say Now
CMS later tightened the rules. Medicare Advantage plans generally must follow national and local Medicare coverage requirements.
When Medicare’s criteria are not fully established, a plan may use internal standards only in limited circumstances, and those standards must be based on current evidence and made publicly accessible. Plans also must have committees review their utilization management policies.
Protections If You Switch Plans Mid-Treatment
There are continuity protections as well. If you are in an active course of treatment and move to a new Medicare Advantage plan, the new plan generally must allow at least a 90-day transition period without requiring fresh prior authorization for that course of treatment.
Once a course of treatment is approved, the authorization must remain valid for as long as it is medically reasonable and necessary under the applicable rules.
A Proposed Fix on the Administrative Side
An April 2026 proposal would extend electronic prior authorization requirements to drugs, standardize more of the information exchange, increase reporting, and set shorter decision deadlines for certain payers.
Many proposed compliance dates would begin in October 2027. It is still a proposal, so it should not be treated as a benefit that is already guaranteed.
Technology may reduce lost faxes, repeated forms, and missing records. But a quick electronic denial can still delay care if the medical standard behind it is flawed.
That is why the new inspector general review matters. The technology project asks how to move decisions faster. The investigation asks whether selected decisions were appropriate in the first place.
What to Do If Your Plan Denies Care
First, read the written notice and identify the exact reason. Ask your doctor’s office whether the plan needs a missing record, a clearer explanation of medical necessity, or proof that another treatment failed or would be unsafe. The national numbers show that additional information and appeals can change outcomes.
Second, follow the deadline and instructions in the notice. Medicare says a first-level Medicare Advantage appeal is called a reconsideration. You, your representative, or your provider generally have 65 days from the date of the initial denial notice to file it. If waiting for the standard process could seriously harm your health, ask whether you qualify for a fast appeal. A doctor can support that request. Our step-by-step guide to appealing a Medicare denial covers the process in more detail.
Third, keep copies of everything. Save the denial, medical records, names, dates, and reference numbers. If the process feels overwhelming, contact your State Health Insurance Assistance Program for free Medicare counseling.
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What This Means for You
If you are in a Medicare Advantage plan, nothing about your coverage changes because of this review. Your plan’s prior authorization rules still apply today.
What the numbers should change is how you react to a denial. A denial is a first answer, not always a final one, and most people never appeal.
And during plan selection, look beyond the premium and the extra benefits. Check the Evidence of Coverage, drug rules, provider network, and prior authorization requirements for treatments you use regularly.
Frequently Asked Questions
What is prior authorization in Medicare Advantage?
It is a requirement that your plan approve certain care before you receive it. Nearly all Medicare Advantage enrollees are in plans that require it for at least some services.
Are Medicare Advantage denials really overturned 80 percent of the time?
Among denials that were appealed in 2024, 80.7 percent were overturned in full or in part. But only 11.5 percent of denials were appealed at all, so that figure describes appealed cases, not every denial.
How long do I have to appeal a Medicare Advantage denial?
You, your representative, or your provider generally have 65 days from the date of the initial denial notice to file a reconsideration. A fast appeal may be available if waiting could seriously harm your health.
What is step therapy for Part B drugs?
It is a rule that can require you to try the plan’s preferred drug before it will cover a different one. Medicare Advantage plans have been allowed to use it for certain Part B drugs since 2019.
Does this federal review change my coverage right now?
No. It is an active review of selected plans and cases. It does not ban prior authorization, and it is not a finding that any particular plan broke the rules.
What happens to my prior authorizations if I switch plans?
If you are in an active course of treatment, the new plan generally must allow at least a 90-day transition period without requiring fresh prior authorization for that treatment.
Key Takeaway
It is not that every authorization is harmful or every denial is wrong. Review can prevent waste and steer care toward effective lower-cost options.
The real test is whether it works as a responsible checkpoint without becoming an obstacle to medically necessary treatment.
For now, three things are worth remembering: a denial is not always final, the appeal deadline is generally 65 days, and prior authorization rules belong on your checklist when you choose a plan.
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Disclosure: We may receive a referral from Chapter if you choose to use their service. Chapter is a licensed health insurance agency and is not affiliated with or endorsed by Medicare or any government agency.
Money Instructor provides educational information only and does not offer medical, insurance, tax, legal, or financial advice. Coverage rules, deadlines, and program details may change or may not apply to your situation. Please verify details with Medicare, your plan, or an official source, and consult a qualified professional before making decisions about your care or coverage.
