Denial Trends by Specialty: 2024 Landscape

Denial rates are not uniform across medicine. A primary care practice submitting routine office visit claims faces a fundamentally different denial landscape than an oncology group seeking authorization for targeted biologics. Understanding where your specialty sits in the broader denial environment — and how that environment is shifting — is essential for strategic planning in 2024 and beyond.

This analysis draws on publicly available data from the Kaiser Family Foundation (KFF), CMS Marketplace transparency reports, the American Medical Association (AMA), and specialty-specific surveys to map the current denial landscape by specialty.

The Broad Picture: Denials Are Rising

The overall trend is unmistakable. KFF's analysis of Marketplace plan data found that insurers denied approximately 17% of in-network claims in 2021, with significant variation by insurer. CMS data from subsequent years suggests this rate has remained stubbornly high. The AMA's 2023 Prior Authorization Physician Survey found that 94% of physicians reported care delays associated with prior authorization, and 80% reported that prior authorization requirements had increased over the previous five years.

Against this backdrop, certain specialties bear a disproportionate share of the denial burden.

Oncology: High Stakes, High Denial Rates

Oncology consistently faces some of the highest denial rates in medicine. The combination of expensive therapies, rapidly evolving treatment protocols, and frequent off-label use creates a perfect storm for utilization management scrutiny. The Association of Community Cancer Centers (ACCC) has reported that prior authorization requirements for cancer treatment increased substantially in recent years, with some practices reporting that more than 50% of drug administrations require prior authorization.

The challenge is compounded by the pace of FDA approvals. When a new indication is approved for an existing drug, payer medical policies often lag by months. During that gap, claims are denied despite being clinically appropriate and FDA-approved. For practices managing patients on immunotherapy or targeted therapy regimens, this creates both financial risk and potential treatment interruptions.

Rheumatology and Specialty Medications

Rheumatology practices face persistent denial pressure centered on biologic medications. Step therapy requirements — which mandate that patients fail less expensive treatments before accessing biologics — remain a major source of denials. The American College of Rheumatology (ACR) has been vocal about the clinical risks of forced step therapy, particularly for patients with aggressive disease presentations where delayed treatment leads to irreversible joint damage.

In 2024, biosimilar adoption has added a new dimension to rheumatology denials. As payers push formulary switches from reference biologics to biosimilars, practices are seeing denials for continuation of therapy that was previously authorized. The clinical argument for non-medical switching — changing a stable patient's medication for cost reasons — is contested, but the denial volume is real and growing.

Orthopedics: Imaging and Surgical Authorization

Orthopedic practices face a two-front denial challenge. Advanced imaging — particularly MRI — faces increasingly stringent prior authorization requirements. Payers have expanded their use of radiology benefit managers (RBMs) to gatekeep imaging orders, and denial rates for advanced imaging have increased accordingly.

Surgical authorization presents the second front. Joint replacement, spinal surgery, and arthroscopic procedures all face detailed medical necessity criteria that vary significantly by payer. The American Academy of Orthopaedic Surgeons (AAOS) has documented cases where payers require months of conservative treatment documentation before authorizing surgery, even when clinical evidence supports earlier intervention.

Cardiology: Diagnostic and Interventional Denials

Cardiology denials cluster around two areas: advanced diagnostic testing and interventional procedures. Cardiac imaging studies — stress echocardiography, nuclear stress testing, and cardiac CT — face prior authorization requirements that have expanded significantly. The American College of Cardiology (ACC) has reported concerns about prior authorization requirements for diagnostic testing that delays identification of life-threatening conditions.

On the interventional side, cardiac catheterization and coronary stenting face detailed appropriateness criteria. Payers have adopted clinical appropriateness guidelines — in some cases more restrictive than those published by the ACC itself — to evaluate these procedures. The disconnect between payer criteria and specialty society guidelines creates a fertile ground for denials.

Primary Care: Volume Over Complexity

Primary care denial rates on a per-claim basis tend to be lower than specialty practices. However, the sheer volume of claims means that even a modest denial rate generates significant administrative work. The most common primary care denial triggers include referral requirements, preventive vs. diagnostic coding disputes, and laboratory authorization requirements.

A notable 2024 trend in primary care is the expansion of prior authorization requirements for diagnostic imaging ordered by primary care physicians. As PCPs manage more complex patients and order more advanced diagnostics, they increasingly encounter the same authorization hurdles that specialists have long faced.

Mental Health and Behavioral Health

Despite the federal Mental Health Parity and Addiction Equity Act, behavioral health services continue to face disproportionate denial rates. A 2023 report from the U.S. Department of Labor found significant compliance gaps in how payers apply medical necessity criteria to mental health services compared to medical and surgical services. Prior authorization for inpatient behavioral health, intensive outpatient programs, and certain medication-assisted treatment protocols remains a significant barrier.

The practical impact is stark: practices report that the administrative burden of behavioral health authorizations discourages providers from accepting insurance, contributing to the access crisis in mental health care.

Common Threads Across Specialties

Despite the variation, several trends cut across all specialties in 2024:

• Increased use of clinical algorithms by payers. Automated systems that evaluate claims against rigid criteria are responsible for a growing share of denials. These systems lack the nuance of clinical judgment and often deny claims that a physician reviewer would approve.
• Shifting criteria without notice. Practices report that payers update medical policy bulletins and coverage criteria more frequently, sometimes without adequate notice. A claim that was approved last month may be denied this month under revised criteria.
• Rising documentation requirements. The volume of documentation required to support claims and appeals continues to increase across all specialties, adding to the administrative burden that the AMA estimates costs physicians and their staff an average of 13 hours per week.
• Medicare Advantage growth. As Medicare Advantage enrollment continues to expand — now covering more than half of Medicare beneficiaries according to KFF — specialties that serve older patients are encountering MA-specific denial patterns that differ from traditional Medicare.

What This Means for Your Practice

Understanding where your specialty sits in the denial landscape is the first step toward a tailored strategy. A practice that benchmarks its denial rates against specialty-specific data — rather than general industry averages — can identify whether its denial challenges are typical for the specialty or whether specific payers or procedures represent outliers that warrant focused intervention.

The specialties with the highest denial rates are not necessarily the ones with the worst outcomes. They are the ones where proactive denial management — including pre-submission documentation, payer-specific workflows, and systematic appeal processes — delivers the greatest return. The data makes the case: in 2024, denial management is not a back-office function. It is a strategic imperative that varies by specialty, by payer, and by procedure.