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Highmark: Medicare Advantage denial & appeal rates

Highmark Health · 1.2% of MA enrollment

Whatever the rate, the pattern that matters is the same everywhere: ~81% of appealed MA prior-authorization denials are overturned, and only about 1 in 9 denials is ever appealed. A denial is rarely the final word — and Highmark’s own filing shows most of the denials its members appealed were approved in the end.

Highmark’s CMS prior-authorization metrics posting →

Insurer / contract level. Medicare does not publish per-plan denial rates. Rates are calendar-year 2025 prior-authorization metrics posted by Highmark under the CMS Interoperability and Prior Authorization rule (CMS-0057-F). "Approved after appeal" is the share of appealed denials that were later approved — not a share of all denials. Data as of September 2026. Notes: Covers Highmark Blue Cross Blue Shield in western/northeastern and central/southeastern Pennsylvania, Delaware, West Virginia and western/northeastern New York, plus Highmark Wholecare. Publishes the most complete Medicare Advantage policy library of the three — including written skilled-nursing and inpatient-rehab medical-necessity criteria, which most plans keep behind licensed InterQual or MCG criteria. Informational only — not medical, legal, or billing advice.