Prior authorization approval rates by documented criteria

Illustrative model based on published denial audit research and CMS OIG analysis

Likely approved High denial risk Very high denial risk
All 6 criteria met
82%
baseline approval
Missing 1 criterion
63%
moderate risk
Missing 2 criteria
44%
high denial risk
Missing 3+ criteria
23%
auto-deny territory

The 6 criteria payer algorithms actually scan for:

Named failed treatments with dates and duration
Functional limitation — specific and measurable
ICD-10 precision matching the requested intervention tier
Severity qualifier (mild / moderate / severe)
Baseline measurements before requested treatment
"Guideline-concordant" or "evidence-based" — exact phrase required

Sources: CMS OIG 2022, AMA Prior Authorization Physician Survey 2022, published claim audit literature. Rates are modeled from denial pattern research — not a single published study. Niti Logic / PRISM Framework