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LUGPA Policy Update – New Data Highlights Wide Variation in Prior Authorization Denials

September 2026

At a Glance

New federal data analyzed by the Kaiser Family Foundation (KFF) provides the first broad look at prior authorization denials across Medicare Advantage (MA), Medicaid managed care, and Affordable Care Act (ACA) Marketplace plans.

KFF found that insurers denied 12% of standard prior authorization requests in Medicare Advantage, 14% in Medicaid managed care, and 18% in ACA Marketplace plans in 2025. Denial rates varied significantly among insurers, ranging from 2% to 25%.

Many denials were ultimately overturned on appeal: 67% in Medicare Advantage, 47% in Medicaid managed care, and 43% in ACA Marketplace plans.

Why It Matters

Prior authorization remains a significant administrative and patient-access challenge for independent urology practices. Different insurers may impose different documentation requirements, approval criteria, and processes for similar services.

These requirements consume staff and physician time and can delay medically necessary care, particularly for patients requiring time-sensitive cancer treatment, procedures, medications, and other complex therapies.

The high rate of successful appeals also raises concerns about whether some initial denials unnecessarily shift administrative and clinical burdens onto physicians and patients.

Implications for LUGPA Members

The findings reinforce the need for greater transparency, consistency, and accountability in prior authorization. Smaller independent practices can be particularly affected because they may have fewer administrative resources to manage complex authorization and appeals processes.

LUGPA supports reforms that reduce unnecessary administrative burdens while maintaining appropriate utilization management.

LUGPA Recommendations

LUGPA recommends:

  • Standardizing requirements for prior authorization, including documentation and clinical criteria.
  • Increasing transparency by requiring insurers to report authorization volumes, denial rates, appeals, and overturn rates by service category.
  • Requiring clear denial explanations that identify the specific basis for a denial and information needed for reconsideration.
  • Expanding exemptions for physicians and practices with demonstrated histories of appropriate utilization and high approval rates.
  • Improving electronic prior authorization to reduce duplicative paperwork and allow practices to track requests and appeals.
  • Strengthening timely appeals, particularly for cancer treatment and other time-sensitive urologic care.
  • Limiting retrospective denials after a service has been authorized and provided, absent fraud or material misrepresentation.
  • Protecting physician-led decision-making so prior authorization does not unnecessarily interfere with evidence-based treatment decisions.

What Comes Next

CMS is pursuing additional changes to improve prior authorization transparency and standardization. However, KFF noted that current data remain incomplete because insurers report percentages rather than total request volumes and provide limited information by service type.

LUGPA will continue to advocate for prior authorization reforms that reduce administrative burdens, improve transparency, and ensure that utilization management does not become a barrier to timely, physician-directed urologic care.