Robert Hall

Imagine getting this message from an insurance company: “The treatment you recommended has been denied.”

You review the documentation. You explain why the patient needs care. You submit an appeal. And then the answer changes to yes.

That’s good news for your patient. But it leaves a question: What did it take to get there—and could that extra work have been avoided?

A recent KFF analysis looked at insurers’ publicly reported prior authorization data for 2025. Among appealed standard prior authorization denials, 67 percent were overturned in Medicare Advantage. The figures were 47 percent in Medicaid managed care and 43 percent in the federally facilitated ACA Marketplace.

Let’s be precise about those numbers. They describe denials that were appealed. They do not mean that 67 percent of all Medicare Advantage denials were reversed. And the analysis covers medical services broadly; it does not give us a physical therapy-specific overturn rate.

Still, there’s a clear message for practices: An initial denial deserves scrutiny. If your clinical record supports treatment, an appeal may be worth pursuing.

There’s also a bigger issue.

A successful appeal doesn’t erase the work required to obtain it.

Someone in your practice assembled the records. Someone wrote the explanation, tracked the response, and talked with the patient. Meanwhile, that patient may have been wondering whether to keep the next appointment—or whether treatment would continue at all.

An eventual approval is only part of the story. We also need to understand the cost of getting that approval.

Now, these findings don’t prove that every initial denial was wrong. Sometimes an appeal includes information that wasn’t available during the first review. Sometimes documentation requirements weren’t clear. And sometimes the initial decision may deserve correction.

Those situations call for different solutions.

If the problem is missing documentation, the payer should clearly identify what it needs up front.

If the same coverage criteria are repeatedly misapplied, the payer should improve its review process.

And if a practice repeatedly wins appeals using information it already submitted, that pattern deserves a serious conversation.

Independent review matters, too. In Medicare Advantage, when a plan upholds its denial at the plan appeal stage, the case automatically goes to an independent review entity. KFF notes that Medicaid managed care and Marketplace coverage do not have the same automatic external medical review process.

That difference may help explain variation in appeal outcomes, although it doesn’t prove the reason for it.

So, what can physical therapy practices do?

Start by tracking more than whether you won or lost.

Record the reason for the denial. Note whether you supplied new information during the appeal. Track staff time and any interruption in treatment.

Then look for patterns.

Are particular services repeatedly denied? Is one documentation issue recurring? Are decisions being reversed based on information the reviewer already had?

Bring those findings to your payer meetings and let us know at Private Practice (Rhall@ppsapta.org).

The goal is timely, accurate decisions at the first review.

Winning an appeal helps one patient. Fixing the process can help the patients who come after them.