Medicare advantage becoming a disadvantage with use of artificial intelligence in prior authorization review

By Sara Raza, Sara Gerke, Christina Silcox, Rachele Hendricks-Sturrup & Carmel Shachar. Published in NPJ Digital Medicine on February 4, 2026.

Artificial intelligence (AI) algorithms are playing a larger role in directing patient care. Insurers are implementing AI algorithms to accelerate prior authorization (PA)and utilization management (UM) reviews, which can potentially benefit patients in the form of rapid access to care or treatment. However, there are concerning reports that the use of AI algorithms has inappropriately denied services that clinicians deem medically necessary. While some denials may be justified to reduce wasteful spending on low-value care, other denials have been deemed wrongful, unreasonable, or harmful for patients. Such denials have delayed time-sensitive treatment, significantly spent down a patient’s life and family savings, and/or worsened already deteriorating health.

These denials can more broadly affect older ( ≥ 65 years) populations in the United States. More than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans (see Box 1). A recent Congressional report concluded that denial rates in UnitedHealthcare, CVS, and Humana’s MA plans jumped significantly after increased uses of AI. Because MA claims face a higher denial and approval delay rate compared to non-MA claims, health systems are increasingly reluctant to participate in MA plans as in-network providers. For example, a Minnesota healthcare organization, HealthPartners, announced that it would no longer accept UnitedHealthcare’s MA plans starting in 2025 due to the denial rate being 10 times higher than other insurers, although ultimately the parties worked out a deal.

These high-profile decisions to stop participating in MA plans are concerning because of the critical role these plans play in access to care, especially for those living in rural areas served by health systems like Essentia Health. These plans also affect MA beneficiaries seeking engagement in pragmatic trials for innovative therapies, whereas clinical or standard of care procedures performed in such trials might rely on specified payer coverage for those procedures.

In this article, we examine real-world challenges associated with AI-driven PA decision-making, especially for MA beneficiaries. We highlight key priorities that health insurers and regulators should consider that allow them to leverage opportunities that increase transparency, reduce provider burnout and patient burden, and make AI-driven coverage determination processes and policies fair and trustworthy.

Read the full article: Medicare advantage becoming a disadvantage with use of artificial intelligence in prior authorization review | npj Digital Medicine