It is becoming clear that Medicare Advantage (MA) plans are systematically limiting access to laboratory testing through prior authorization requirements, creating a two-tiered healthcare system where beneficiaries face barriers that traditional Medicare patients never encounter. Prior authorization barriers create diagnostic delays, and the scope of this problem has exploded over the past decade.

What To Know: Per McKnight, “Medicare beneficiaries in MA plans — now more than half of all insured — have the right to the same care as individuals enrolled in traditional or Fee-for-Service Medicare.”  Though federal laws require Medicare Advantage plans to cover the same basic benefits as traditional Medicare, and that should prohibit disparities in coverage in theory, the reality appears much different. Guidelines called Internal Coverage Criteria allow for denials where Medicare rules don’t fully specify coverage requirements, creating arbitrary barriers that traditional Medicare never imposes. 

The Kaiser Family Foundation (KFF) reported in 2018 that “80 percent of Medicare Advantage enrollees are in plans that require prior authorization for at least one Medicare-covered service”. A more recent review of 2023 data, published by KFF in 2025, found the same troubling trends.

As described in the report, “In 2023, there were nearly 2 prior authorization determinations on average per Medicare Advantage enrollee, similar to the amount in 2019. In contrast, in 2023, about 1 prior authorization review was submitted per 100 traditional Medicare beneficiaries – a rate of about 0.01 per person — which reflects the limited set of services subject to prior authorization in traditional Medicare.”

Laboratory-specific challenges compound these problems, with Medicare as the largest payer of clinical laboratory services nationwide.

Such denials create a complex appeals process that discourages patients and providers from pursuing rightful coverage. Under traditional Medicare, physicians order necessary blood work, patients receive testing the same day, and results guide immediate treatment decisions.

Real Impact: Many common tests for nursing home residents now face several hurdles. Hemoglobin A1C tests for diabetes management, ordered over 17 million times annually for Medicare beneficiaries, now face authorization delays. Comprehensive metabolic panels assessing kidney, liver, and heart function, ordered 40 million times yearly, require pre-approval that can delay urgent care decisions. Cholesterol testing for cardiovascular disease prevention, crucial for the over 28 million heart disease tests ordered annually, faces similar barriers.

Skilled nursing facilities encounter particularly severe challenges with Medicare Advantage laboratory testing access, creating dangerous gaps in care for the nation’s most vulnerable patients. The authorization requirements transform routine monitoring into complex bureaucratic processes that delay essential care for residents who cannot advocate for themselves.

The clinical impact particularly affects residents requiring frequent laboratory monitoring. A single resident may need multiple authorizations for different aspects of care, each subject to separate review processes and potential denials, while the administrative burden consumes enormous staff time. The American Hospital Association (AHA) found in their February 2022 survey that “84% of respondents said the cost of complying with insurer policies was increasing and 95% of hospitals and health systems reported that their staff were spending more time on prior approval processes.”

Yet, the vast majority of these denials that receive an appeal end up overturned. KFF found from 2019 to 2023 that, “more than eight in ten (81.7%) denied prior authorization requests that were appealed were overturned.” The same analysis, however, found that “just one in 10 prior authorization requests that were denied in 2022 were appealed”. In practice, this could mean thousands receive improper denials that they never challenge.

Patient advocacy organizations have mobilized unprecedented efforts to address laboratory testing access barriers through legislative initiatives and organized campaigns, such as the American Clinical Laboratory Association’s “Stop Lab Cuts” Campaign or the College of American Pathologists’ advocacy on changes for issues like PAMA data collection. Advocates urge that prior authorization should only be used to confirm diagnoses or medical criteria and ensure medical necessity, while eliminating arbitrary coverage restrictions that served plan financial interests rather than medical appropriateness.

Healthcare providers cannot sustain the current trajectory. Medicare Advantage laboratory testing restrictions represent a fundamental threat to American healthcare quality, creating dangerous delays in essential diagnostic care while imposing billions in administrative costs on providers and patients.