Recent headlines suggest (incorrectly) that prior authorization is no longer the obstacle it once was. Health insurers have highlighted new data showing that fewer than 1% of prior authorization requests are denied, implying that recent reforms have largely solved one of medicine’s greatest administrative frustrations.
According to AHIP, participating insurers report they eliminated approximately 6.5 million prior authorization requests, an 11% reduction in medical prior authorizations. However, the experiences of physicians and patients suggest a different reality.
Insurers have not publicly identified which medical services no longer require prior authorization or which health plans account for those reductions. The reported improvements apply only to medical services—not prescription drugs, where many allergy practices continue to experience significant prior authorization challenges.
Moreover, one year after the initiative was announced, some participating insurers have acknowledged they will not implement every promised reform, and the federal accountability dashboard that was expected to track progress has yet to materialize. Recent reporting has also highlighted potential gaps in implementation, including reports of retroactive payment denials after prior authorization had already been granted and inconsistent application of continuity-of-care protections for patients who change health plans.
As prospective authorization rules tighten, payers are placing greater reliance on post-payment review and retroactive denial, especially for allergy shots. The voluntary industry pledge does not prohibit that practice. These developments underscore why physicians remain skeptical that voluntary commitments alone will meaningfully reduce the administrative burden of prior authorization.
An article published this month by Axios examined new data from Silna, a company that analyzes prior authorization activity. While outright denials were reported to be less than 1%, approximately 15% of requests for physical, occupational, and speech therapy were only partially approved. In many cases, physicians were not told “no;” they were told “not exactly.” A request for 20 therapy visits might be approved for only eight, or a recommended treatment plan might be modified by the health plan. Those cases are often counted as approvals, yet they still result in additional paperwork, repeated authorizations, treatment delays, and increased costs for patients.
For allergists, this distinction is particularly important. Prior authorization is rarely a simple yes-or-no decision. More commonly, practices encounter requests for additional documentation, repeat laboratory testing, step therapy requirements, shortened authorization periods, or restrictions on dosing and treatment schedules. Biologic therapies, allergen immunotherapy, and other evidence-based treatments may eventually be approved, but only after physicians and their staff spend hours navigating administrative hurdles. From the patient’s perspective, delayed treatment often feels no different than a denial.
Recent federal reports reinforce these concerns. The HHS Office of Inspector General (OIG) found that Medicare Advantage plans overturned nearly all prior authorization denials for skilled nursing facility admissions after they were appealed, suggesting that many medically necessary services were initially denied inappropriately. Earlier OIG reports similarly documented high denial rates for post-acute care services, with many decisions later reversed. These findings raise an important question: if so many denials are ultimately overturned, why were patients and physicians forced through the appeals process in the first place?
Analysis from KFF paints a similar picture. Medicare Advantage plans processed more than 52 million prior authorization requests in 2024, resulting in more than four million full or partial denials. Yet only a small percentage of denials were appealed, despite the fact that the vast majority of appeals were successful. Many patients never receive the treatment originally recommended by their physician—not because it was medically inappropriate, but because the administrative burden of appealing became too great.
This is why measuring success solely by denial rates misses the point. A prior authorization system should not be judged simply by how often it says “no.” It should be judged by whether patients receive timely, evidence-based care without unnecessary administrative barriers. Every request for additional documentation, every peer-to-peer review, every repeated authorization, every shortened approval period, and every insurer-directed modification of a physician’s treatment plan consumes valuable physician and staff time while delaying patient care.
These issues are not theoretical for ACAAI members. The College continues to advocate aggressively on behalf of allergists and their patients with CMS, Medicare Administrative Contractors (MACs), Medicare Advantage organizations, and commercial insurers. Recent efforts have focused on ensuring appropriate reimbursement for allergen immunotherapy, preserving coverage of the buildup phase of immunotherapy, addressing inconsistent MAC policies, challenging inappropriate restrictions on allergen extract preparation and diluent coverage, and reducing unnecessary prior authorization requirements for evidence-based allergy treatments. While important progress has been made, including CMS clarification supporting coverage of immunotherapy buildup dosing, significant work remains to ensure that coverage policies reflect current clinical practice and do not create unnecessary barriers to care.
ACAAI is also pursuing legislative solutions. Working closely with Congressman Bob Onder, MD, FACAAI, the College helped develop the Allergy and Asthma Patient Protection (AAPP) Act – legislation specifically designed to address administrative and reimbursement challenges unique to allergy and immunology practices. The AAPP Act would protect patient access to allergen immunotherapy and other essential allergy services, preserve appropriate reimbursement for evidence-based care, and reduce unnecessary administrative burdens imposed by commercial health plans. Unlike broader prior authorization reform proposals, the AAPP Act directly addresses many of the issues allergists encounter every day and represents an important step toward ensuring that clinical decisions remain in the hands of physicians rather than insurance companies.
The bottom line is simple: a reported 1% denial rate may make for a reassuring headline, but it does not reflect the day-to-day experience of allergy practices across the country. Until patients can receive the treatments their physicians recommend without unnecessary delays, repeated paperwork, and insurer-directed modifications of evidence-based care, prior authorization will remain one of the most significant administrative burdens facing our specialty.
The ACAAI Advocacy Council will continue working with CMS, Medicare Administrative Contractors, health plans, Congress, and other policymakers to reduce these barriers and ensure that clinical decisions remain where they belong – in the hands of allergists and their patients.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
Sources
- Insurers hedge on Trump-backed pledge to improve denials process. Fierce Healthcare. July 17, 2026. Fierce Healthcare article
- Reed T. Why prior authorization woes haven’t disappeared. Axios. July 14, 2026.
Axios article- Source of the Silna data reporting:
- <1% complete denial rate
- ~15% partial approval rate for therapy services
- Discussion of why partial approvals still burden physicians and patients.
- Source of the Silna data reporting:
- Office of Inspector General, U.S. Department of Health and Human Services.
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials.
HHS OIG Report- Found that nearly all appealed prior authorization denials for skilled nursing facility admissions were overturned, raising concerns that medically necessary care was initially denied.
- Office of Inspector General, U.S. Department of Health and Human Services.
The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates.
HHS OIG Report- Documents high denial rates for post-acute care among major Medicare Advantage plans.
- Biniek JF, et al. Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024. KFF.
KFF Analysis- Reports:
- 52.8 million prior authorization requests
- More than 4 million full or partial denials
- Only a small percentage appealed
- More than 80% of appeals overturned
- Reports:
