Prior authorization denial statistics

Prior authorization denial statistics are the approval rates, denial rates, and decision turnaround times payers publish for medical items and services that need prior authorization. Under the CMS Interoperability and Prior Authorization final rule (CMS-0057-F), impacted payers must post those metrics on a public website each year. CMS does not publish one national denial percentage that rolls every plan into a single number. You read each payer's posted table, then compare scope, year, and definitions.

This page is a citation hub for those numbers and for the reporting rules behind them. For what prior authorization is and how a request usually moves, see Prior authorization (/answers/prior-authorization). For appeal steps after a denial letter, see How to appeal a health insurance denial (/blog/how-to-appeal-a-health-insurance-denial) and Insurance denials and appeals (/answers/health-insurance-denials-and-appeals).

What CMS-0057-F requires payers to report

Beginning in 2026, and annually thereafter, impacted payers must post aggregated prior authorization metrics from the previous calendar year on a public-facing website. Password-only portals do not count. The metrics cover medical items and services subject to prior authorization and exclude drugs.

CMS lists these metrics for each reporting year:

A list of all items and services that require prior authorization (excluding drugs), written so patients and providers can understand it. A bare CPT code list without descriptions does not meet the public-list expectation in CMS's reporting template.

For standard (non-urgent) requests: the percentage approved, the percentage denied, the percentage approved after appeal, and the average (mean) and median time from when the payer receives the request to when it decides.

For expedited (urgent) requests: the percentage approved, the percentage denied, and the average and median decision times. CMS's metrics FAQ treats the expedited approved-after-appeal percentage as optional in the template notes.

Across requests: the percentage where the review timeframe was extended under program rules and the request was then approved.

CMS also says the total approved count should include requests approved after appeal, and the total denied count should include requests denied after appeal, so the overall rates reflect every request outcome. Appeals metrics aggregate all appeal levels the payer's program counts as an appeal. Each prior authorization request is counted separately, even when several sit inside one episode of care.

Which plans, and when the first numbers appear

Under CMS-0057-F, the impacted payers are: Medicare Advantage organizations; Medicaid and Children's Health Insurance Program (CHIP) fee-for-service programs run by states; Medicaid managed care plans; CHIP managed care entities; and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges.

Public posts sit at different reporting levels by program. Medicare Advantage organizations publish at the contract level. Medicaid managed care plans and CHIP managed care entities publish at the plan level. State Medicaid and CHIP fee-for-service programs publish at the state level. QHP issuers on the Federally-facilitated Exchanges publish at the issuer level.

CMS's FAQ states that the first required public post is calendar year 2025 metrics, due on payer websites by March 31, 2026. The CMS fact sheet for CMS-0057-F likewise says the initial set of metrics must be reported by March 31, 2026, with operational prior authorization policies starting January 1, 2026. Those posts live on each payer's site. They are not a CMS national dashboard with one denial rate for the whole country.

Metrics are not the only CMS-0057-F transparency change. Starting January 1, 2026, the rule also shortens many non-QHP decision windows to 72 hours for expedited requests and seven calendar days for standard ones, and it requires a specific written denial reason for covered items and services (drugs stay out). Those are process rules next to the annual rate tables, not a substitute for a published denial percentage.

Medicare Fee-for-Service baselines CMS already publishes

Before the CMS-0057-F payer posts, CMS already published program statistics for selected Original Medicare Fee-for-Service prior authorization and pre-claim review initiatives. Those figures are not Medicare Advantage plan rates, not Marketplace issuer rates, and not the CMS-0057-F annual metrics format. They cover specific services under Medicare Fee-for-Service. Fiscal Year 2024 in that CMS document runs from October 1, 2023 through September 30, 2024.

For the nationwide hospital outpatient department prior authorization program in Fiscal Year 2024, CMS reports 422,435 prior authorization requests received, 423,830 completed, and 335,656 provisionally affirmed, which is 79.2 percent of completed requests that received a provisional affirmation.

For the nationwide repetitive, scheduled non-emergent ambulance transport prior authorization model in Fiscal Year 2024, CMS reports 29,901 requests received, 28,836 completed, and 20,888 provisionally affirmed, or 72.4 percent provisionally affirmed.

For prior authorization of certain durable medical equipment, prosthetics, orthotics, and supplies items in Fiscal Year 2024, CMS reports 193,140 requests received, 175,577 completed, and 127,994 provisionally affirmed, or 72.9 percent provisionally affirmed. Among expedited requests in that DMEPOS program, CMS reports 7.4 percent approved and 93 percent denied.

CMS's Fee-for-Service language uses provisional affirmation and non-affirmation. That is a coverage-likelihood decision before the item or service is furnished or before the claim is paid. It is related to, but not identical to, the approval and denial percentages CMS-0057-F asks managed care, Medicaid, CHIP, and Marketplace issuers to post.

How to read a denial rate

A fair place to start is the year and the population on the page. A calendar year 2025 Medicare Advantage contract table is not the same object as a Fiscal Year 2024 Medicare Fee-for-Service outpatient program table.

You could keep standard and expedited rows separate. Decision clocks differ, and denial rates often do too.

A fair question is what sits in the denominator. CMS's metrics FAQ says each prior authorization request counts once for reporting, including multiple requests inside one episode of care. Approved-after-appeal is a share of appealed requests in the template notes, not a second copy of the overall approval rate.

You could watch drugs versus items and services. CMS-0057-F prior authorization metrics and process rules exclude drugs. A plan's drug prior authorization numbers, if published elsewhere, follow other program rules.

Mean and median turnaround are worth reading together. CMS's reporting template asks payers to state time units in hours or calendar days, and to report sub-day medians in hours rather than rounding to zero days. Time starts when the payer receives the request.

A personal denial notice is a different artifact from a payer's annual metrics table. HealthCare.gov's internal-appeals page sets written-notice windows for many Marketplace-style claims: 15 days when prior authorization is sought, 30 days after services already happened, and 72 hours when the case is urgent. Those windows are for reading your letter. They are not the public approval and denial percentages on a payer website.

What this page is not

This page does not walk through how to file an appeal. It does not diagnose why your request was denied. It does not replace the definition and waiting-room guidance on Prior authorization (/answers/prior-authorization), or the appeal timelines on How to appeal a health insurance denial (/blog/how-to-appeal-a-health-insurance-denial) and Insurance denials and appeals (/answers/health-insurance-denials-and-appeals).

It also does not invent a single United States prior authorization denial rate. Until CMS publishes a national rollup, the citable public numbers are the per-payer CMS-0057-F tables and the Medicare Fee-for-Service program statistics CMS posts for named initiatives.

Keeping letters and records while numbers catch up

If you are waiting on a request, store the outcome letter, the submission date, the reference number, and the service description the plan reviewed. Triangle can hold those letters and records together. Triangle does not submit prior authorization requests or file appeals.