Denials based on lack of prior authorization are often reversed, data shows

By the Editorial Team · Monday, July 6, 2026

Jane Hvatum, a Medicare Advantage enrollee under Humana, faced denials for essential medication and hospital bills due to prior authorization issues after switching plans, which led to treatment interruptions and serious health complications. Her case highlights widespread challenges and administrative burdens in the Medicare Advantage system’s prior authorization process, prompting limited insurer commitments to ease these requirements despite ongoing patient hardships.

A Medicare Advantage enrollee’s struggle with insurance denials highlights ongoing challenges with the prior authorization process, which requires insurer approval before patients can obtain certain medications or treatments.

After switching to a Humana Medicare Advantage plan in early 2026, Jane Hvatum faced denial of coverage for Hizentra, a medication she needs. Humana did not recognize the prior authorization from her previous insurer, leading to a lapse in treatment. This interruption contributed to Hvatum developing a urinary tract infection that necessitated an emergency room visit and an overnight hospital stay. Despite the hospitalization, Humana denied payment for the $18,000 bill, citing that her condition did not meet the criteria for inpatient care.

Hvatum’s experience illustrates a widespread phenomenon. In 2024, Medicare Advantage plans reviewed nearly 53 million prior authorization requests, a volume equivalent to almost two reviews for every enrollee, according to data from the Kaiser Family Foundation. More than half of the approximately 35 million Medicare beneficiaries who select Medicare Advantage are subject to such processes, which insurers use to manage costs.

Experts note that Medicare Advantage companies profit when enrollees’ medical expenses fall below the fixed government payments they receive. Carrie Graham, director of the Medicare Policy Initiative at Georgetown University’s Center on Health Insurance Reforms, said denials help plans generate profits by limiting covered care. Humana and UnitedHealthcare make up nearly half the Medicare Advantage market.

The killing of UnitedHealthcare CEO Brian Thompson in 2025, linked by police to anger over health care denials, intensified scrutiny of prior authorization practices. Following his death, major insurers including Humana signed a pledge to ease prior authorization burdens by reducing required approvals and honoring existing authorizations for a 90-day period when patients switch plans. However, Humana clarified that this commitment applies only to medical services and excludes prescription medications, which did not help Hvatum’s case.

Humana said prior authorization performs a valuable role by verifying treatments align with patient safety and controlling taxpayer spending, acknowledging the process can be frustrating. In mid-2025, Humana announced it would eliminate a third of prior authorization requirements for outpatient services to streamline care.

After appealing, Hvatum secured coverage for Hizentra, but the approval was temporary and expires at year-end, forcing another authorization request. She has since switched medications and is considering relocating to Norway, where her husband holds citizenship and she could access universal health care.

Hvatum has also appealed denials for her hospital stays following her infection and a stroke in March 2026. Humana initially rejected claims, questioning the necessity of inpatient admission, but reversed both decisions following appeals. She attributes her hospitalizations to delays caused by Humana’s initial denial of her medication.

Although data indicates that appeals lead to overturning denials in 81 percent of Medicare Advantage cases, few patients pursue appeals due to the complexity and exhaustion involved. Both patients and providers often find the administrative burden onerous, fueling public criticism of prior authorization requirements and motivating the industry’s pledge to reform.

This article was reported by synthesizing coverage from multiple independent news outlets to present a balanced, unbiased account. Read about our editorial standards. Spotted an error? Let us know.