By Dr. Steve Kim, Valer Co-Founder and CEO
This is Part 8 of our 10-part series examining the deep, interconnected complexities that keep prior authorization broken. While many hospital and health systems hope new regulation (CMS-0057-F) and AI will improve processes, the real barriers to progress lie in systemic challenges that span technology, workforce, regulation, and operations. These barriers won’t be eliminated by regulation, payer pledges, or today’s AI solutions—but providers have more control than they might think. Throughout the series, we’ll break down the entire prior auth landscape and include practical recommendations that can make a difference.
Your patient access team receives a prior authorization denial. The notification offers minimal explanation: “Does not meet medical necessity criteria” or “Additional information required” or simply “Denied per plan guidelines.” Now comes one of the most frustrating aspects of prior authorization—deciding whether to appeal and, if so, unraveling which of the many previous steps went wrong.
Was it a coverage issue where the service isn’t actually a covered benefit? Was it insufficient clinical documentation? Did the wrong provider-facility combination get submitted? Was there an administrative error in how the request was coded or formatted? Or did the payer apply undisclosed criteria that even perfect documentation couldn’t have satisfied?
The appeals process requires staff to work backward through the entire prior authorization journey, investigating each potential failure point without clear guidance on what actually caused the denial. This detective work happens under time pressure, as appeal deadlines approach and patients wait for clarity about their care.
Challenge #1: Untangling Root Causes from Vague Denial Reasons
Denial notices rarely provide specific, actionable information about why the authorization was rejected. Generic statements like “does not meet medical necessity criteria” force staff to guess which clinical elements were deemed insufficient. “Additional information required” doesn’t specify what information or why the originally submitted documentation wasn’t adequate.
This vagueness makes it nearly impossible to determine whether an appeal has any chance of success. Staff must decide whether to:
- Gather additional clinical documentation and resubmit
- Request peer-to-peer review between the ordering physician and payer medical director
- Appeal the decision through formal channels
- Accept the denial and explore alternative treatment approaches
- Proceed with the service and risk claim denial
Each option consumes time and resources, but without clear understanding of the denial reason, staff are making decisions based on incomplete information. CMS 0057F now requires impacted health plans to provide a clear denial reason, but it is yet to be seen how transparent and clear reason codes will be from payer to payer.
The investigation process requires staff to revisit every step of the original submission, and this root cause analysis is complicated by the fact that multiple issues may have contributed to the denial simultaneously. Perhaps the clinical documentation was sufficient but got submitted under the wrong provider NPI. Or maybe the documentation was incomplete AND the service required approval from a delegated TPA rather than the primary payer.
The solution: Implement systematic denial analysis processes that categorize denial reasons and track patterns across payers and service types. This institutional knowledge helps staff more quickly identify likely root causes and develop targeted response strategies. Technology solutions that maintain detailed records of what was submitted—including exact documentation, provider information, and submission pathways—make investigation significantly more efficient.
Challenge #2: Inconsistent Appeal Pursuit Across Organizations
Healthcare organizations vary dramatically in how aggressively they pursue prior authorization appeals. Some have dedicated appeal teams that systematically work every denial. Others pursue appeals only when physicians specifically request it. Many have no systematic approach at all, with appeal decisions made ad-hoc based on staff capacity and perceived likelihood of success.
This inconsistency stems from the resource-intensive nature of appeals combined with uncertain success rates. Appeals require staff time to investigate denials, gather additional information, prepare appeal documentation, and follow up on appeal status. For high-volume organizations dealing with hundreds of denials monthly, pursuing every appeal would require significant staffing increases.
The lack of reliable data about appeal success rates makes it difficult to determine which denials are worth pursuing. Without tracking which types of denials are most likely to be overturned and which payers are most responsive to appeals, organizations can’t make informed strategic decisions about where to focus limited appeal resources.
The result is that many legitimate appeals never get pursued simply because organizations lack capacity or systematic processes to identify which denials should be challenged. This effectively allows payers to benefit from denials that would be overturned if appealed but aren’t challenged due to provider resource constraints.
The solution: Develop clear criteria for which denials warrant appeal based on service value, likelihood of success, and organizational capacity. Track appeal outcomes systematically to identify patterns—which payers overturn denials most frequently, which denial reasons are most likely to be reversed, and which types of services have the highest appeal success rates. Use this data to make strategic decisions about appeal investment. Denials management and appeals has been an area of focus for the application of AI/genAI which may also reduce both the manual labor and time for appealing denials.
Challenge #3: Retrospective Denials and Medical Necessity Black Box
Some of the most frustrating denials happen retrospectively—after services have already been delivered based on an initial authorization approval. These denials claim the service didn’t meet medical necessity criteria that may not have been clearly stated when the original authorization was submitted.
Retrospective denials create enormous financial and operational challenges. The patient has already received care, often at significant cost. The provider delivered services in good faith based on authorization approval. Now both parties face unexpected financial liability because the payer applied criteria that weren’t transparent during the authorization process. This will in all likelihood become a mainstay of the new CMS WISeR requirements for select services in traditional Medicare with the option for pre-payment review which can wreak havoc on the revenue cycle if not appropriately planned for.
These retrospective denials are particularly common when initial authorization was granted by non-physician reviewers using screening criteria, but subsequent claim review by medical directors applies additional proprietary guidelines that weren’t part of the initial authorization decision. The authorization becomes essentially meaningless—a temporary green light that can be retroactively revoked based on undisclosed standards.
The medical necessity determination process itself remains largely a black box. Payers maintain proprietary clinical criteria that evolve without clear communication to providers. What constituted medical necessity last month may not this month, but providers have no systematic way to stay current with these changing standards.
This opacity makes appeals particularly challenging. How do you argue that services met medical necessity criteria when you don’t know what those criteria actually are? Staff find themselves trying to guess what additional clinical information might satisfy unknown standards, often through multiple appeal rounds before either succeeding or exhausting appeal options.
The solution: Document everything meticulously during the initial authorization process, including all communications with payers and exact clinical information submitted. When facing retrospective denials, demand specific citations of the criteria that weren’t met and evidence that these criteria were accessible to providers during the authorization process. Consider escalating patterns of retrospective denials to state insurance commissioners or filing complaints when payers systematically apply undisclosed criteria.
Challenge #4: Regulatory Gaps Leave Appeals Process Largely Unchanged
While CMS-0057-F brings new requirements for prior authorization transparency and electronic transactions, it notably does not regulate the appeals process itself. The focus remains on initial authorization submissions and decisions, leaving the appeals mechanism largely untouched by reform efforts.
Starting on January 1, 2026, Medicare Advantage, Medicaid, CHIP, and Qualified Health Plans on the Federally Facilitated Exchanges will need to report on the percentage of prior auth requests denied and the reasons for those denials. That is a step in the right direction, but only for those plans, and in all cases the cumbersome appeals process itself is unchanged.
Payers can still maintain proprietary medical necessity criteria beyond basic authorization requirements. Retrospective denials can still occur based on claim review that applies different standards than initial authorization. And administrative errors in submission or processing can still result in denials regardless of how clear the requirements are.
Organizations still need dedicated resources to investigate denials, prepare appeal documentation, and navigate payer-specific appeal processes that vary as dramatically as submission processes do.
The solution: As with so many other components of the prior auth maze, navigating the appeals process is a workflow challenge. Consider a centralized platform where you can track the reasons for any and all prior authorization denials so that your team can easily analyze patterns and develop standardized processes for follow-up.
The Strategic Importance of Appeals Management
Organizations that take appeals seriously as a strategic function see different results. By tracking denial patterns, measuring appeal success rates, and developing expertise in navigating payer-specific appeal processes, they recover revenue that would otherwise be lost and create accountability pressure on payers to improve initial authorization accuracy.
Perhaps most importantly, effective appeals management protects patients from unexpected financial liability. When prior authorizations are denied and services have already been delivered, someone must bear the cost. Organizations that successfully appeal denials protect patients from surprise bills while recovering legitimate revenue.
Beyond Appeals: Preventing Denials in the First Place
While improving appeals processes is important, the ultimate goal should be preventing denials that require appeals in the first place. This requires addressing all the upstream challenges covered in previous parts of this series: clear authorization requirements, accurate provider-facility matching, complete clinical documentation, reliable submission processes, and effective status tracking.
Every denial represents a failure somewhere in the prior authorization system. Some failures are unavoidable given current payer practices and regulatory frameworks. But many denials stem from preventable errors, incomplete information, or process gaps that organizations can address through better workflows, training, and technology.
Organizations that reduce their denial rates through upstream process improvements not only save appeal resources but also improve patient experience, accelerate care delivery, and reduce administrative costs. The ROI of denial prevention far exceeds the ROI of even the most effective appeals management.
Next up in Part 9: How practices like gold carding, which allows some prior auths to be eliminated, may seem to relieve the administrative burden but in many cases only increases it.
Frequently Asked Questions About Prior Authorization Appeals
When should I appeal a prior authorization denial?
High-dollar services, procedures with urgent clinical need, and denials with vague or questionable reasoning are typically worth appealing. Before investing appeal resources, investigate the denial reason to determine if it’s correctable—administrative errors and incomplete documentation are more likely to be overturned than legitimate coverage or medical necessity determinations. Track your organization’s appeal success rates by payer and denial type to make data-driven decisions about which appeals to pursue.
How long do I have to appeal a prior authorization denial?
Appeal timeframes vary by payer and insurance type. Review the denial notice carefully for specific appeal deadline information. Missing appeal deadlines eliminates your ability to challenge the denial, so implement tracking systems that flag approaching deadlines and ensure timely submission. Some payers have multiple appeal levels with different timeframes for each level.
What information do I need to include in a prior authorization appeal?
Effective appeals require specific documentation that addresses the stated denial reason. Include all original authorization request information plus additional clinical documentation that strengthens the medical necessity case. If the denial cited insufficient documentation, identify exactly what was missing and provide it with a clear explanation of its relevance. For administrative errors (wrong codes, incorrect provider information), provide corrected information with explanation of the error. Request peer-to-peer review when medical necessity is questioned—direct physician-to-physician discussion often resolves clinical disputes more effectively than written appeals. Document all communications and maintain detailed records of what was submitted and when.
