Medically reviewed by Dr. Jennifer Frangos, D.O., DABOM — board-certified physician with experience in hormone optimization and insurance access support
Last updated: April 2026
Around 80%+ of insurance appeals succeed, but only about 11% of patients actually appeal. The biggest issue isn’t denial—it’s that most people stop before completing the process.
You get denied.
It feels final.
But the data says otherwise.
Most denials are not the end—they’re just the part where most people stop.
How common are prior authorization denials?
Prior authorization (PA) is required before many treatments are approved.
Here’s what recent data shows:
| Metric | Data |
|---|---|
| Total PA requests (Medicare Advantage) | ~53 million/year |
| Initial denial rate | ~7.7% |
| Appeal rate | ~11.5% |
| Appeal success rate | ~80%+ |
? Most requests are approved
? Most denials are never challenged
What these numbers actually mean
For every 100 prior authorizations:
-
- ~92 are approved immediately
- ~8 are denied
- only ~1 person appeals
- ~4 out of 5 appeals succeed
? The biggest gap is not approval—it’s action
Why appeals succeed so often
Appeals are not random—they succeed for specific reasons:
-
- initial denials are often automated
- additional documentation changes decisions
- peer-to-peer reviews introduce clinical context
- insurers reconsider when challenged
? Most denials are incomplete—not impossible
If you’re dealing with this, this insurance denial guide explains how to approach the process step by step.
Appeal success rates by type
| Appeal Type | Typical Success Rate |
|---|---|
| Medical necessity | 75–85% |
| Experimental/investigational | 80–90% |
| Step therapy exceptions | 60–75% |
| Formulary exceptions | 50–70% |
? The type of denial affects your strategy
If step therapy is involved, this step therapy guide explains how to document your case properly.
Why most patients never appeal
Even with high success rates, most people don’t move forward.
Common reasons:
-
- they think denial is final
- the process feels complicated
- lack of provider support
- time and effort required
? This is where most opportunities are lost
The cost of not appealing
When patients stop early:
-
- they may miss covered treatments
- they may pay out-of-pocket unnecessarily
- they may switch to less effective options
? The system often depends on patients not continuing
Denial rates by insurer
| Insurer | Denial Rate |
|---|---|
| UnitedHealthcare | 12.8% |
| Aetna | 14.4% |
| Humana | 10.2% |
| Cigna | 8.9% |
| Average | ~7.7% |
? Denial rates vary—but appeal success stays high
Denial reasons and what they mean
Not medically necessary
-
- most common
- high success rate when documentation is added
Experimental or investigational
-
- often overturned for FDA-approved treatments
Not a covered benefit
-
- lowest success rate
- usually tied to plan design
If this is your case, this formulary exclusion guide explains what options still exist.
Step therapy required
-
- can often be resolved with documentation
- requires proof of prior medication trials
The external review option
If internal appeals fail, external review is available.
| Region | Success Rate |
|---|---|
| California | ~91% |
| National average | 60–70% |
? External review removes insurer bias
What the data really tells you
-
- most treatments get approved
- most denials can be overturned
- most patients stop too early
? The outcome often depends on whether you continue
What to do if you’re denied
-
- review the denial reason
- gather missing documentation
- request peer-to-peer review
- submit an appeal
- escalate to external review if needed
? The first denial is rarely the final decision
Where Amazing Meds fits in
At Amazing Meds, provider visits and labs are billed to your insurance. Coverage and out-of-pocket costs depend on your plan. Medication is self-pay. We do not provide prior-authorization or appeal services.
Book a free consultation with our care team to discuss how care works and whether we can help.
FAQ
What percentage of prior authorizations are denied?
About 7–8% of prior authorization requests are denied initially, depending on the plan.
How often do appeals succeed?
Around 80–83% of appeals result in approval when properly submitted with documentation.
Why don’t more patients appeal denials?
Many patients assume denials are final, or find the process confusing and time-consuming.
What is the most common reason for denial?
Missing documentation, incorrect coding, or incomplete prior authorization submissions.
Is it worth appealing a denial?
Yes. Based on current data, most appeals succeed—especially when supported by clinical documentation.