OIG OEI-09-18-00260 — Some MA Organization Denials of Prior Authorization Requests Raise Concerns

A sample of denied prior-authorization requests found that 13% of the denials, and 18% of denied payment requests, actually met Medicare's own coverage rules and should not have been denied.ruleOIG (April 2022): Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns — OEI-09-18-00260

The report specifically flagged Medicare Advantage plans' use of their own internal clinical criteria — criteria not found in Medicare's own coverage rules — as a factor behind some of these incorrect denials, the same concern the 2024 rule (CMS-4201-F) later addressed by requiring internal criteria to be public and evidence-based.

A meaningful share of denials are wrong on the plan's own terms, not just arguable — a real reason to check the actual rule against your denial rather than assume the plan's first answer was final.

If a denial cites the plan's own internal policy or clinical guideline rather than a specific Medicare rule by name, that's exactly the pattern this report found problematic — worth checking whether that internal policy is even allowed to apply here.

The two figures this report is best known for — 13% of denials and 18% of denied payment requests not meeting Medicare's own rules — came from OIG's own review of a random sample of denials, not from disputed or borderline cases hand-picked to make a point. That's part of why this finding carries real weight.

The report also recommended CMS take specific steps to increase oversight of Medicare Advantage organizations' prior-authorization and payment-denial decisions, including reviewing plans with high denial rates or overturn rates — oversight that continued in the reports that followed it.

This report was published roughly two years before the 2024 rule (CMS-4201-F) tightened how internal coverage criteria can be used — part of the same broader federal record documenting concerns about Medicare Advantage denial practices during that period.

The underlying standard this report checked plan decisions against was Medicare's own coverage rules — not any plan's internal policy — the same real, external standard CaseWhy Appeals' own explanations are grounded in.