Prior authorization and appeals data

Prior Authorizations for Services Provided from

January 1, 2023 to December 31, 2023

This information shows:

  • How many prior authorization (PA) requests were authorized.
  • How many PA requests were denied. They are sorted by healthcare service, whether there was an appeal and whether the denial was upheld or reversed after the appeal.
  • How many PA requests were submitted electronically and not by fax, email or another way.

Service Category Total Approvals Denials Approval Rate Electronically submitted Total Appeals Upheld Overturned
Alternative Medicine 14 12 2 86% 13 1 1 0
Ambulance 4 2 2 50% 3 0 0 0
Cancer Treatment 382 256 126 67% 467 1 0 1
Home Care/Hospice 84 58 26 69% 76 7 3 4
Imaging 32,983 24,139 8,844 73% 33,156 7 5 2
Injectable Drug 3,798 3,103 695 82% 3,285 16 6 10
Inpatient Psychiatric 212 207 5 98% 158 3 3 0
Inpatient Services 390 371 19 95% 305 3 1 2
Inpatient Substance Abuse 597 573 24 96% 477 4 0 4
Medical Care 23,839 19,160 4,679 80% 23,509 59 24 35
Medical Dental 163 153 10 94% 139 0 0 0
Medical Equipment 263 191 72 73% 234 17 5 12
Outpatient Medical 2,478 2,246 252 90% 2,458 31 20 11
Outpatient Therapies 74 74 0 100.0% 47 0 0 0
Prescription Drug (Prime Therapeutics) 66,334 49,338 16,996 74% 53,970 3,832 1,896 1,936
Psychiatric Care 5 5 0 100.0% 5 0 0 0
Substance Abuse 29 28 1 97% 26 1 1 0
Surgical Services 4,575 3,747 828 82% 4,405 167 56 111
Transplant Services 41 41 0 100.0% 24 0 0 0
Vision (Davis Vision) 29 25 4 86% 0 0 0 0
Totals 136,294 103,709 32,585 76% 122,757 4,149 2,021 2,128


View 2022 Blue Cross prior authorization and appeals data

Service Category Total Approvals Denials Approval Rate Electronically Submitted Total Appeals Upheld Overturned
Ambulance 1 0 1 0.0% 1 0 0 0
Cancer Treatment 142 111 31 78.17% 164 0 0 0
Home Care/Hospice 15 13 2 86.67% 12 0 0 0
Imaging 10,204 7,605 2,599 74.53% 10,268 0 0 0
Injectable Drug 653 509 144 77.95% 622 4 2 2
Inpatient Psychiatric 15 15 0 100.0% 9 1 0 1
Inpatient Services 92 87 5 94.57% 83 2 0 2
Inpatient Substance Abuse 61 55 6 90.16% 37 0 0 0
Medical Care 6,015 5,038 977 83.76% 6,024 5 4 1
Medical Dental 17 16 1 94.12% 17 0 0 0
Medical Equipment 26 16 10 61.54% 24 1 1 0
Outpatient Medical 330 293 37 88.79% 348 8 4 4
Prescription Drug (Prime Therapeutics) 2,217 1605 612 72.40% 1,962 673 300 373
Psychiatric Care 1 1 0 100.0% 1 0 0 0
Substance Abuse 3 3 0 100.0% 3 0 0 0
Surgical Services 1,105 926 179 83.80% 1,106 23 8 15
Transplant Services 11 11 0 100.0% 11 0 0 0
Totals 20,908 16,304 4,604 78.0% 20,692 717 319 398


View 2022 Blue Plus prior authorization and appeals data

Reasons for denials

Prior authorization requests may have been denied for these reasons.

Blue Cross and Blue Shield of Minnesota and Blue Plus:

  • Change in treatment program
  • Services are not considered to be medically necessary
  • Patient did not meet prior authorization criteria
  • Incomplete information submitted by the provider to the utilization review organization
  • The patient is no longer covered by the plan

Delegates (Prime Therapeutics, Davis Vision):

  • Did not meet prior authorization criteria
  • Incomplete information submitted
  • Inactive coverage/no plan coverage
  • Change in treatment program
  • Other

This information meets Minnesota Statute 62M.18 requirements.