The Centers for Medicare & Medicaid Services (CMS) published a final rule Wednesday requiring Medicare Advantage organizations to publish prior-authorization approval and denial rates by procedure code, along with median decision times and overturn rates on appeals.
Patient advocacy groups have pressed for machine-readable PA metrics for years, arguing that secret denial patterns make it impossible for enrollees and clinicians to anticipate coverage friction before treatment.
What advocates should watch
- Plans must post quarterly PA dashboards starting January 2027, with retroactive data back to 2025 where available.
- Denial letters must cite the published policy identifier used in the automated edit.
- Expedited PA decisions for Part B drugs remain subject to existing 72-hour standards; the rule does not shorten them.
CMS says the transparency requirements apply to Medicare Advantage and Part D plans but not Original Medicare fee-for-service. Employer-sponsored plans are unaffected unless they mirror MA contract terms voluntarily.
Advocate tip:When a denial cites a plan policy, request the public dashboard row for that procedure and compare your client's specialty, site of service, and diagnosis codes to the published denial rate band.
Using transparency dashboards in appeals
When dashboards launch, compare your client's procedure code, site of service, and diagnosis against published denial bands. Attach dashboard screenshots to reconsideration requests when a denial appears inconsistent with published rates.
Original Medicare fee-for-service is not covered by this rule; employer plans are unaffected unless they voluntarily adopt similar reporting.
Guides on patientadvocates.io
For step-by-step help, start with our Medicare Advantage guide or browse related topics including Rx prior authorization, Appeals roadmap.