Insurer record · Medicare Advantage, marketplace, and Medicaid across PA, NY, WV, DE
of standard MA requests denied on its largest contract (H3916), 2025
Dataset: Prior-authorization postings · payers' own sites · CY2025
Duplicate tables found See the public-record check →
| Measure | What the insurer reported | Note |
|---|---|---|
| Standard requests, contract H3916 | 463,352 | |
| Denied | 4% | 18,072 denials |
| Appeals won by patients | 78% | of 1,333 appeals |
| DSNP contract (H5932) denial rate | 12% | 3× its mainline rate |
| Marketplace (FFE) denial rate | 8% | only 43 appeals filed on 120,652 requests |
| Duplicated tables found | 3 contracts |
Start with the facts in your notice. The builder adds public context only when it matches Medicare Advantage prior authorization, and labels that context so it is not confused with evidence about your individual request.
The block below is for Medicare Advantage prior-authorization appeals only.
I ask that my Medicare Advantage prior-authorization appeal be reviewed carefully. I include the following public figures as background only; they do not describe my individual request and do not, by themselves, show that this denial was incorrect: - KFF's analysis of insurer-reported CMS data found that 80.7% of appealed Medicare Advantage prior-authorization denials were overturned in 2024. CMS does not audit these insurer submissions (https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/). - Highmark’s 2025 posting for Medicare contract H3916 reports that 78% of 1,333 appealed prior-authorization denials were decided in the member’s favor. (https://providers.highmark.com/authorization/obtaining-authorizations/prior-authorization-metrics.html). Please reconsider my individual request on its facts, provide the specific criteria used, and identify the credentials of any clinician who reviewed it.
Highmark's dual-eligible special-needs contract (H5932) — covering low-income members on both Medicare and Medicaid — shows a 12% denial rate, three times the 4% on its mainline contract.
See how these figures are collected, what they can and cannot tell you, and how to request a correction on the methodology page. Compare payers on the rankings page.