Medicare Advantage plans denied 6.4% of 50 million prior authorization requests in 2023, according to recent data. However, 81.7% of those denials were overturned on appeal, highlighting the importance of understanding and navigating the appeals process.
Prior authorization is a requirement that doctors obtain approval from a health plan before prescribing certain treatments or services. It's common for high-cost items like advanced imaging (MRI, CT scans), durable medical equipment (oxygen, wheelchairs), and expensive prescription drugs. In Original Medicare, prior authorization applies mainly to durable medical equipment and certain Part B drugs, but Medicare Advantage plans have broader lists.
The appeals process includes five levels:
- Internal appeal – The plan reviews its own decision.
- Independent review – An external organization reviews the case.
- Office of Medicare Hearings and Appeals (OMHA) – An administrative law judge hears the case.
- Medicare Appeals Council – Review by a council within the Department of Health and Human Services.
- Federal court – The last resort.
To build a winning appeal, it's crucial to:
- Get a detailed denial letter explaining why the care was denied.
- Obtain a letter of medical necessity from your doctor.
- Submit all supporting medical records.
- Meet deadlines – usually 60 days for standard appeals and 72 hours for expedited.
- Request an expedited appeal if waiting could harm your health.
Understanding the appeal process is key to fighting back against wrongful denials and obtaining the care you need.