What Aetna's Commercial Prior Authorization Data Shows About Denials, Appeals, and the Economics of Friction

Farzin Espahani

VHealth Partners·LinkedIn

Prior authorization is intended to help health plans manage utilization, confirm coverage requirements, and prevent inappropriate or unnecessarily expensive care.

The newly available commercial prior authorization data from Aetna gives us a better opportunity to examine how that process works after a request actually enters the system.

The most useful questions go beyond the denial rates alone:

• ·How many denials are appealed?
• ·What happens when providers or patients do appeal?
• ·Why are requests being denied?
• ·Who absorbs the work required to challenge a denial?
• ·What happens financially when that challenge never occurs?

A denial often does not end the clinical process. It starts another administrative process for the physician, hospital, pharmacy, or patient.

When challenging that decision requires additional time, documentation, staff work, and clinical involvement, many denials will never be appealed. That has both an operational and financial consequence.

Aetna's Illinois Data: Nearly Three in Ten Requests Were Denied

Aetna publishes state-level prior authorization reports where required by state law. The company says these reports cover commercial insured plans, primarily employer coverage.

Aetna's 2025 Illinois report separates Aetna Health Inc. and Aetna Life Insurance Company. Combining the two reported commercial populations produces the following results:

VHealth.ai calculations based on counts reported by Aetna. Percentages are rounded. Source: Aetna, 2025 Illinois Prior Authorization Report.

Put those numbers into simpler operating terms. For every 100 reported denials in Illinois:

• ·Roughly 92 did not reach a reported appeal.
• ·About 8 were appealed.
• ·Roughly 4 of the original 100 denials were eventually overturned.
• ·Among the small group that did reach appeal, slightly more than half were reversed.

The 53.6% overturn rate does not mean that 53.6% of Aetna's initial denials were necessarily incorrect. An appeal may include additional clinical records, treatment history, or other information that was unavailable during the initial review.

Even so, when very few denials are appealed and more than half of appealed denials are reversed, the initial decision effectively becomes the final decision for most requests.

Colorado Shows a Similar Pattern

Illinois is one market. Aetna's Colorado commercial data provides another useful comparison.

VHealth.ai calculations based on counts reported by Aetna. Percentages are rounded. Source: Aetna, 2025 Colorado Prior Authorization Report.

Roughly 95% of reported Colorado denials did not reach an appeal. Yet among the denials that were appealed, slightly more than half were reversed.

Illinois and Colorado have different populations, utilization patterns, benefit designs, and reporting requirements. The results should not be treated as a controlled comparison. The workflow pattern is still similar. Most denials remain unappealed, while roughly half of appealed denials in both states were reversed. The workflow design determines outcomes as much as the coverage rules do.

Minnesota Shows Why Requests Are Being Denied

Aetna's Minnesota report provides another useful perspective because it breaks adverse determinations down by reason. The company reported 12,018 prior authorization requests in 2025. Its denial-reason table listed 4,352 adverse determinations.

Source: Aetna, 2025 Minnesota Prior Authorization Report.

Quantity limits, plan exclusions, formulary exclusions, and step therapy together accounted for 3,262 of the 4,352 listed adverse determinations, approximately 75%. Only 25% were classified as "not medically necessary."

Prior authorization is often discussed primarily as a way to determine whether requested care is medically appropriate. The Minnesota data shows that much of the process also involves benefit design and utilization controls.

• ·Quantity limits restrict how much of a medication can be covered.
• ·Step therapy can require a patient to try another treatment before the requested treatment is approved.
• ·Formulary and plan exclusions determine what the benefit covers in the first place.

These controls can have legitimate purposes. Health plans have a responsibility to manage unnecessary utilization and control costs for employers and members. The operating question is whether those controls are applied with enough accuracy, clinical flexibility, transparency, and accountability to justify the burden they create.

The Economics Start After the Denial

The financial incentives become clearer when we look at what happens next. When an authorization is denied, the health plan has completed its initial decision.

The provider may then need to:

• ·retrieve medical records,
• ·document treatment history,
• ·submit additional clinical information,
• ·arrange a peer-to-peer review,
• ·communicate with the patient,
• ·resubmit the request, or
• ·file a formal appeal.

The patient may wait during that process. The provider may keep pursuing approval, the patient may switch to another treatment or pay out of pocket, and in some cases the care never happens.

The American Medical Association's 2025 physician survey, published in 2026, provides context for that workload. Among 1,000 physicians surveyed, practices reported completing an average of 40 prior authorizations per physician each week and spending approximately 13 hours of physician and staff time per week on prior authorization. Forty percent reported employing staff dedicated specifically to prior authorization work.

The same survey found:

• ·95% of physicians said prior authorization delays necessary care.
• ·79% reported patients abandoning treatment because of prior authorization challenges.
• ·74% said prior authorization denials had increased during the previous five years.
• ·32% said prior authorization requests were often or always denied.

These are physician-reported survey results, not claims data. They should be interpreted accordingly. They still help explain why low appeal rates matter. Appealing a denial is not free. The cost is paid in physician time, staff time, delayed schedules, administrative capacity, and patient effort.