Prior Authorization in Medicare: What It Is, Why Plans Deny Care, and How to Fight Back
Watch on YouTube Medicare Advantage plans denied 6.4 percent of 50 million prior authorization requests in 2023 - but 81.7 percent of those denials were overturned on appeal. This episode explains exactly what prior authorization is, which services require it, how the five-level appeal process works, and how to build an appeal that wins. Watch the next video in this playlist for the full Medicare Advantage vs. Original Medicare decision framework. Verify details at Medicare.gov or contact your State Health Insurance Assistance Program (SHIP) at shiphelp.org.
▶ Watch next: Medicare Advantage vs. Original Medicare: The Decision Framework https://www.youtube.com/watch?v=d8BUeYjGh78
📺 Full playlist: Medicare (US - 2026) https://www.youtube.com/playlist?list=PLlIAFxS29648I08akd—o7PeoOBzdOb2S
Chapters
Prior authorization is the process where your Medicare Advantage plan (or starting in twenty twenty-six, even Original Medicare for certain services in six states) must approve a treatment before you receive it. In twenty twenty-three, Advantage plans processed nearly fifty million prior auth requests and denied six point four percent. But eighty-one point seven percent of those denials were overturned on appeal — meaning millions of people were initially denied care they were entitled to. This episode teaches viewers exactly how to navigate and fight the prior auth system.
Key Topics
- What prior authorization is: a requirement that your plan approve a service before it is delivered, or the plan will not pay
- Common services requiring prior auth in Advantage plans: imaging (MRI, CT), specialty drugs, durable medical equipment, skilled nursing, home health, and some surgeries
- The new prior auth in Original Medicare: starting January first, twenty twenty-six, CMS is requiring prior auth for seventeen procedures in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington)
- Denial rates and appeal success: six point four percent of requests denied, but eighty-one point seven percent overturned on appeal — always appeal a denial
- The five-level appeal process: redetermination (sixty-day decision), reconsideration by a QIC, ALJ hearing (minimum two hundred dollar threshold in twenty twenty-six), Medicare Appeals Council, federal district court (minimum one thousand nine hundred sixty dollar threshold)
- Expedited appeals: if waiting could seriously harm your health, request an expedited review — the plan must respond within seventy-two hours instead of thirty days
- Documenting everything: keep copies of all denial letters, appeal submissions, and medical records — and ask your doctor to write a letter of medical necessity