Study Highlights Barriers in Medicare Advantage Coverage Leading to Patient Access Issues

Recently, Walnut Hill Medical published the findings of its Medicare Advantage Denial (MAD) Study, shedding light on the substantial barriers patients face when trying to access crucial treatments. The study focused on identifying systemic issues within Medicare Advantage plans, particularly concerning coverage for non-opioid, non-steroidal chronic pain therapy called Peripheral Nerve Stimulation (PNS). The analysis was based on a proprietary dataset involving 1,210 patients who sought prior authorization for PNS treatment in 2024, and the results are concerning.

Understanding the Complexity of Medicare Advantage Plans

Medicare Advantage, or Medicare Part C, presents a private alternative to traditional Medicare and has become the choice for over half of all Medicare beneficiaries. While these plans often promise additional benefits, they also introduce stricter controls and require prior authorization for many medical services. This process necessitates healthcare providers to obtain approval from insurers before administering treatment. Although intended to ensure the medical necessity of services and control costs, prior authorization can lead to delays in patient care and even denials.

In a significant warning issued by the Office of Inspector General (OIG) in 2022, it was reported that 13% of denied services had met the necessary criteria for coverage. The OIG raised alarms about plans potentially restricting essential care, and the data from Walnut Hill indicates that the situation might have worsened in 2024.

Alarming Findings: Delays and Denials in Accessing Pain Treatment

The study revealed that 29% of patients were denied their initial request for prior authorization for PNS, a figure that far exceeds the OIG's 2022 statistics. Moreover, the data also showed that nearly 28% of patients opted to abandon their treatment journey following an initial denial, choosing not to appeal or resubmit their requests. Among those who did challenge their decisions, 56% managed to have their denials reversed, and an impressive 69% who escalated their cases to a Medicare hearing found approval for their treatments.

Chris Hanna, the CEO of Walnut Hill Medical, refers to prior authorization as not merely an administrative task but as a barrier that can prevent patients from receiving the care they require. "This isn't just inefficiency; it's a sorting mechanism that weeds out patients without time, resources, or strong clinical advocates," he stated, highlighting the financial and emotional costs associated with these hurdles.

The Financial Toll of Denials

The study also calculated that among the 1,210 patients analyzed, 210 were denied and did not receive their PNS therapy. This denial resulted in an estimated $6.2 million of care being withheld from patients, emphasizing how administrative barriers can reduce healthcare costs at the expense of patient well-being.

Call for Legislative Action

In light of these findings, Walnut Hill Medical advocates for lawmakers to strengthen the transparency and accountability provisions in the bipartisan Improving Seniors' Timely Access to Care Act of 2025. "With the dominant coverage of Medicare Advantage among eligible seniors, it is crucial that there is responsibility accompanying this power. Our data indicates that, without reform, prior authorization will continue to act as a silent gatekeeper, denying patients necessary care, not just delaying it," Hanna added.

The full details of the MAD Study, encompassing the methodology, detailed statistics, and patient-level analysis, can be accessed online. This research aims to empower innovators and ensure physicians can prioritize patient care without facing administrative hindrances.

Conclusion

The findings from the Walnut Hill study serve as a clarion call for both the healthcare industry and policymakers. As an increasing number of seniors rely on Medicare Advantage for their healthcare needs, addressing these systemic barriers is essential. The implications of these delays and denials are profound, affecting not just patient access but overall health outcomes for those who depend on these critical treatments.