Contract: H5521 · Plan type: HMO
Evidence lead: Top-three record · Large request-volume cohort
The 980,000 recorded requests place this contract in the highest-volume tier. Its request-volume rank is #3 of 37. Volume shows the denominator behind approvals and denials; it is not a measure of plan quality, membership, benefit breadth, price, or future coverage decisions.
Top-three record · Large request-volume cohort
The 980,000 recorded requests place this contract in the highest-volume tier. Its request-volume rank is #3 of 37. Volume shows the denominator behind approvals and denials; it is not a measure of plan quality, membership, benefit breadth, price, or future coverage decisions.
Ranks four through six · Higher denial-rate cohort
CVS Health / Aetna MA's 11.2% denial rate is in the highest group of the comparison. The exact rank is #6 of 37. This is aggregate prior-authorization activity for the reporting window, not a probability that a particular service, drug, or beneficiary request will be denied.
Ranks seven through ten · High overturn-rate cohort
75.0% of this contract's filed appeals were overturned in the source record. Its overturn-rate rank is #10 of 37. The denominator is filed appeals, not all authorization requests. The percentage therefore describes reviewed appeals and must not be read as an individual outcome forecast.
Ranks seven through ten · Broad reversal reach
12,348 overturned appeals equal 11.3% of every denial recorded for this contract. The cross-contract rank is #10 of 37. This derived measure combines appeal filing and outcome, so it supplies scale context but does not identify clinical reasons, administrative errors, or coverage rules.
Ranks eleven through fifteen · Upper-middle appeal uptake
The 16,464 filed appeals represent 15.0% of denied requests. That is rank #11 of 37 for filing share. The ratio reports aggregate activity; it cannot reveal why an appeal was or was not filed, whether the underlying cases were comparable, or what happened outside the reporting window.
| Metric | Value |
|---|---|
| Prior Authorization Requests | 980,000 |
| PA Approved | 870,240 |
| PA Denied | 109,760 |
| Appeals Filed | 16,464 |
| Appeals Overturned | 12,348 |
Data: CMS OIG OEI-09-22-00380 and KFF 2023 Medicare Advantage analysis. Not affiliated with CMS. ← All MA plans
Read our methodology - how this data is sourced, computed, and verified.