How to appeal a denial for no prior authorization

Prior authorization, also called preauthorization, precertification or prior approval, is a plan's decision that a service, treatment plan, prescription drug or medical equipment is medically necessary. Plans may require it for certain services before you receive them, except in an emergency, and an approval is not a promise the plan will pay.

A missing-authorization denial is about process. The plan is saying it never received or approved a request, which may show up on your Explanation of Benefits as reason code 197, precertification/authorization/notification/pre-treatment absent.

Start with the doctor's office or hospital that provided the care, since it may have submitted the request. In Medicare Advantage, you, your representative or your health care provider can request a coverage decision. Ask the office:

• Whether a request was submitted, on what date, and its reference number.
• Whether the plan approved it, denied it or asked for more information.
• Whether the approval matched what was billed: the same procedure code, dates, provider and location. A mismatch can look like no approval at all.

If an in-network provider skipped the step, ask the provider's billing office and the plan whether the provider may bill you for the denied amount, and get the answer in writing. In Medicare Advantage, when a plan provider refers you to another provider without getting an approval in advance, you usually will not pay more than the plan's usual cost sharing.

Ask whether your plan will review the request now. Some plans call this retroactive or retrospective authorization, and the rules and time limits vary by plan. Useful questions:

• Does the plan accept retroactive authorization requests, and what is the deadline?
• Will the plan review the claim for medical necessity instead of denying it only for the missing step?
• If I appeal, will the reviewer look at whether the care met the plan's criteria?

If the plan says no, appeal. Include the records that show the care met the plan's criteria, a letter from the doctor if possible, and anything that explains why approval was not obtained first, such as an urgent situation or a referral from your plan's own doctor. For deadlines, see the pages for employer plans, Marketplace plans, Medicare Advantage, Original Medicare and Medicaid.

For plan years starting on or after January 1, 2022, group health plans and insurers that cover emergency room care must cover emergency services without the need for any prior authorization, even out of network. That rule is in 45 CFR 149.110, which applies from the 2022 plan year. The older rule at 45 CFR 147.138(b) covers only plan years before 2022.

Whether it was an emergency is judged by the prudent layperson standard: symptoms, including severe pain, severe enough that a person with average knowledge of health and medicine could reasonably expect serious harm without immediate care. Plans may not decide what counts as an emergency based only on diagnosis codes. Medicare Advantage plans must cover emergency services regardless of whether there is prior authorization.

If the denial involves emergency care, describe in the appeal the symptoms that brought you in, not only the final diagnosis.

A federal rule known as CMS-0057-F, finalized in January 2024, sets decision deadlines for Medicare Advantage plans, Medicaid and CHIP fee-for-service programs, and Medicaid and CHIP managed care plans. With a compliance date starting January 1, 2026, these plans must send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests. Medicare Advantage's seven-day limit is in 42 CFR 422.568, and Medicaid managed care plans follow it for rating periods that start on or after January 1, 2026.

Beginning in 2026, these plans must give a specific reason when they deny a prior authorization request. Marketplace plans sold on the federal exchange must also give that reason, but the decision deadlines exclude them. The rule does not apply to prior authorization for drugs, and employer plans are not on its list of covered payers.

In Medicare Advantage, once a plan approves a service in advance, it may not later deny coverage for lack of medical necessity, except in narrow cases such as fraud.

Original Medicare is testing a prior authorization process for a short list of services through a model called WISeR, which runs from January 1, 2026 to December 31, 2031 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Examples include skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis.

Providers in those states can choose to request prior authorization or have the claim reviewed before payment. The model excludes emergency services and does not apply to Medicare Advantage. If you have Original Medicare in one of those states and a claim is denied, see Original Medicare appeals.