How to Appeal a Prior Authorization Denial
Had your prior authorization denied? According to the 2024 AMA Prior Authorization Survey,31% of PA requests are often or always denied. But here's the good news: 82% of appeals succeed. This guide shows you how to fight back.
Key Statistics: Prior Authorization Denials (AMA 2024)
- 31% often/always denied — Physicians reporting PA request denials (AMA 2024 Survey)
- 81.7% of appeals overturned — Fully or partially when physicians appeal (AMA 2024)
- 39 PAs per week — Average prior authorizations physicians complete (AMA)
- 94% report care delays — Physicians saying PA delays patient access (AMA Survey)
Appeals Work: 82% Success Rate
According to the AMA, 81.7% of appealed prior authorization denials are fully or partially overturned. Don't give up!
The Impact of Prior Authorization Denials
According to the AMA's 2024 survey, prior authorization denials have serious consequences for patients:
94%
of physicians say PA delays patient access to care
82%
report patients abandon treatment due to PA delays
29%
report PA caused serious adverse events (hospitalization/death)
80%
say PA denials force patients to pay out-of-pocket
Why Prior Authorizations Get Denied
Not Medically Necessary
The insurer's clinical guidelines don't support the treatment. Often overturned with additional documentation from your physician.
Step Therapy Required
You must try cheaper treatments first. If you've already tried and failed other treatments, document this in your appeal.
Incomplete Information
Missing documentation, test results, or clinical notes. Resubmit with complete records.
Out of Network Provider
The provider or facility isn't in your plan's network. May be overturned if no in-network alternative exists.
Experimental/Investigational
The treatment is considered experimental. Cite FDA approval and clinical guidelines in your appeal.
Standard vs. Expedited Appeals
Standard Appeal
- • Decision within 30 days
- • For non-urgent treatments
- • Full documentation review
- • Submit in writing
Expedited Appeal
- • Decision within 72 hours
- • For urgent medical situations
- • When delay could harm patient
- • Request from your physician
Source: CMS External Appeals regulations
Step-by-Step: How to Appeal a Prior Authorization Denial
Review the Denial Reason
Read the denial letter carefully. It must state the specific reason and the clinical criteria used. You have the right to request the insurer's clinical guidelines.
Work With Your Physician
Your doctor is often better positioned to appeal. According to the AMA, physicians can request peer-to-peer review with the insurer's medical director to discuss the case directly.
Gather Supporting Documentation
Collect medical records, test results, treatment history, and clinical guidelines that support the treatment. Include records of failed prior treatments if step therapy is required.
Submit a Formal Written Appeal
Include a letter of medical necessity from your physician, all supporting documentation, and a clear argument addressing the denial reason. Reference clinical guidelines and FDA approvals.
Request External Review If Needed
If the internal appeal is denied, you have the right to an external review by an independent third party. According to research, 60-80% of external reviews overturn denials.
Sample Prior Authorization Appeal Letter
Frequently Asked Questions: Prior Authorization Denials
How often are prior authorizations denied?
According to the 2024 AMA survey,31% of physicians report PA requests are often or always denied. 73% say denial rates have increased over the past 5 years.
What is the success rate for PA appeals?
According to the AMA,81.7% of appealed prior authorization denials are fully or partially overturned. Appeals are highly effective.
What is a peer-to-peer review?
A peer-to-peer review is when your physician speaks directly with the insurance company's medical director to discuss the clinical necessity of the treatment. This often resolves denials quickly.
How do I request an expedited appeal?
For urgent medical situations, request an expedited appeal through your physician. According to CMS regulations, expedited decisions must be made within 72 hours.
Related Appeal Guides
About This Guide
This guide is provided for educational purposes only and does not constitute medical or legal advice. Statistics cited are from the American Medical Association's 2024 Prior Authorization Physician Survey.
Always work with your healthcare provider when appealing prior authorization denials.