Your child's speech therapist submits a prior authorization request. Three weeks later, the insurance company denies it without explanation. You call. The representative reads from a script about "medical necessity criteria" but won't tell you what those criteria are or how your child's case failed to meet them. Until now, that denial rate (how often this insurer says no) was invisible.

As of March 31, 2026, it's not invisible anymore.

Insurers were required to publish their prior authorization denial rates publicly for the first time under CMS Rule CMS-0057-F. The numbers are damning. Medicare Advantage plans denied prior authorization requests at rates ranging from 2% to 49% across 175 reporting plans. Oscar Health denied 25.3% of requests. Kaiser Permanente denied roughly 6%. The average plan that uses prior authorization selectively (requiring it for fewer services) denies at higher rates. Overall, denials jumped 56% in 2024 compared to 2023, with nearly 53 million prior authorization requests submitted.

For families seeking ABA therapy, speech therapy, occupational therapy, or durable medical equipment like wheelchairs and AAC devices, this transparency deadline changes the appeal equation. You can now look up your insurer's denial rate and cite it in your appeal. The plan denied 38% of requests last year, and the national median is 18%. You can use that gap to demand clinical justification.

What the March 31 Transparency Deadline Means

Under CMS-0057-F, Medicare Advantage plans and ACA marketplace plans must now publish data on:

• Total prior authorization requests submitted
• Denial rate by service category (outpatient therapy, DME, inpatient care)
• Average decision timeframes (how long approvals and denials took)
• Appeal outcomes (how many denials were overturned)

This data must be posted publicly in a machine-readable format and updated quarterly. It's the first time insurers have been required to disclose how often they deny coverage and for which services.

A federal review found that some denied requests met Medicare coverage rules. Families were told no when the answer should have been yes. The transparency requirement was designed to surface exactly that pattern.

New April 2026 Rules Give Families Concrete Rights

CMS-0057-F includes additional requirements that went into effect April 2026:

72-hour decisions for urgent requests. If your child needs therapy to prevent serious deterioration in function, the plan must approve or deny within 72 hours. If they miss the deadline, the request is automatically approved.

7-day decisions for standard requests. Non-urgent prior authorizations must be decided within seven calendar days. No more three-week waits without explanation.

No reversed approvals once care begins. If a plan approves a therapy session and your child attends, the insurer can't reverse the approval retroactively and deny payment unless there's documented fraud or clear administrative error. This closes the practice of approving care upfront and denying claims after the service is delivered.

90-day continuity of care when switching plans. If you change insurance mid-year (because you switched jobs, aged out of a parent's plan, or enrolled in a new Medicare Advantage plan), the new insurer must continue your child's existing therapy authorizations for 90 days. You don't lose access while the new plan reviews the case.

AI disclosure required. If an insurer uses automated decision-making tools to deny a prior authorization, they must disclose that fact and provide a pathway to human review.

Each of these requirements is enforceable. When a plan violates a timeline or procedural right, you can cite the specific rule in your appeal.

How to Look Up Your Insurer's Denial Rate

CMS has not yet published a centralized portal for this data. Insurers are required to post it on their own websites in a machine-readable format, typically under a section labeled "Quality and Performance Data" or "Prior Authorization Transparency Reporting."

To find your plan's data:

1. Log into your insurance member portal or go to the insurer's main website.
2. Search for "prior authorization transparency" or "CMS-0057-F reporting." Some plans label this "Quality Reporting" or "Performance Metrics."
3. Download the CSV or JSON file. The data is machine-readable, which means it's formatted for analysis tools, not casual browsing. You may need to open it in Excel or Google Sheets.
4. Look for the denial rate by service type. Plans report denial rates by category: outpatient therapy, DME, specialty drugs, inpatient admissions. Find the category that matches your child's denied service.

If your plan hasn't posted the data or you can't locate it, call member services and request the prior authorization denial rate report required under CMS-0057-F. Document the call. If they don't provide it, you can escalate the compliance failure to your state insurance commissioner.

How to Use This Data in an Appeal

When you appeal a therapy denial, you're not just arguing that your child needs the service. You're making a procedural case that the plan applied its criteria inconsistently.

Here's how to frame it:

Cite the plan's own denial rate. "According to your CMS-0057-F transparency report for Q1 2026, you denied 34% of outpatient therapy prior authorization requests. The national median denial rate for similar services is 18%. I'm requesting you explain specifically how my child's case differs from the 66% of requests you approved."

Reference the federal finding. "A 2025 federal review found that some denied Medicare Advantage prior authorization requests met Medicare coverage criteria. Given your plan's above-average denial rate and the documented pattern of inappropriate denials, I'm asking for a second-level review by a clinician with pediatric therapy expertise."

Invoke the new timelines. "This request was submitted March 15, 2026. It's now April 8. Under CMS-0057-F, standard prior authorizations must be decided within seven days. Your failure to meet that timeline constitutes an automatic approval. I'm requesting confirmation of coverage by end of business tomorrow."

Flag retroactive reversals. "You approved 12 ABA therapy sessions on February 10, 2026. My child attended all 12. On March 20, you reversed the approval and denied payment for sessions already delivered. CMS-0057-F prohibits retroactive approval reversals except in cases of fraud or clear administrative error. You've alleged neither. I'm requesting immediate reinstatement of payment."

You're not asking them to reconsider. You're documenting a procedural failure and holding the plan to the rule.

What the Transparency Data Doesn't Show

The Trump administration suspended health equity reporting requirements in June 2025. That means denial rates by disability status are not publicly available. Plans must report overall denial rates, but they're not required to break down whether people with intellectual disabilities, autism, or mobility impairments face higher denial rates than the general Medicare Advantage population.

Georgetown University's Center on Health Insurance Reforms described people with disabilities as "the most vulnerable enrollees" under prior authorization systems. Without disability-specific reporting, that vulnerability remains statistically invisible. Advocates continue to push for restoration of the equity reporting mandate, but as of April 2026, it's not in effect.

What Families Can Do Right Now

Document every interaction. Keep a log of when you submitted the prior authorization request, when the plan responded, and what reason they gave for denial. Note the representative's name and reference number for every call.

Request the denial in writing. Verbal denials don't create an appeal record. Ask the plan to send written notice including the specific coverage criteria your child's case allegedly failed to meet.

Check your plan's posted denial rate. If it's above the national median, cite that gap in your appeal and request clinical justification for how your case differs from approved requests.

Use the new timelines as deadlines. If a plan misses the 72-hour urgent or 7-day standard timeline, document it and request automatic approval under CMS-0057-F.

Escalate to the state insurance commissioner. If your plan refuses to comply with the transparency reporting requirement or violates the procedural timelines, file a complaint with your state insurance department. CMS rules create enforceable rights, not suggestions.

Connect with advocacy coalitions. The American Physical Therapy Association released a "Care Delayed Is Care Denied" framework in March 2026 calling for further prior authorization reform. Disability Rights Advocates and DREDF track compliance failures and file pattern-based complaints when insurers systematically violate the new rules.

If you need step-by-step guidance on structuring an appeal, how to appeal an insurance denial for speech, OT, or ABA therapy walks through the full process. If the denial stands and you're searching for alternative funding, therapy grants for autism, speech, and OT when insurance says no covers grant programs that don't require prior authorization.

The Path Forward

Congress is considering the Improving Seniors Timely Access to Care Act, which would codify the transparency reporting requirements and close loopholes that allow some plans to avoid disclosure. As of April 2026, it hasn't passed. The current rules depend on CMS enforcement, which means future administrations could weaken or eliminate them.

What won't change is the data that's already been published. Families now have a baseline. If your plan denied 42% of therapy requests in Q1 2026 and that rate climbs to 58% in Q2, you can document and challenge that pattern. Transparency doesn't guarantee approval, but it removes the insurance company's ability to say "we don't track that" when you ask how often they deny.

The March 31 deadline opened the black box. What families do with that data determines whether transparency becomes accountability.