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Prior Authorization Non-Affirmative Decision: Resubmissions vs Appeals

When you submit a prior authorization request and receive a non-affirmative prior authorization decision, it's considered an incomplete prior authorization request (PAR). A non-affirmative prior authorization (PA) decision means Medicare reviewed the request and determined that if a claim is submitted for the DMEPOS item, it is unlikely to meet Medicare's coverage, coding, or payment rules.

The DME MACs send a letter that explains what documentation is missing. They send this letter by fax, mail, esMD, or through the myCGS® Web Portal.

If you receive a non-affirmative decision, you have 2 options:

  • Resubmit the PAR with all required documentation. There's no limit on resubmissions, and you'll get a decision within 5 business days. This is the fastest way to get approval and avoid delays in patient care. The easiest way to submit or resubmit is through myCGS Web Portal.
  • Submit a claim with the non-affirmative UTN. The claim will be denied, and you can then file an appeal. You'll get a decision within 60 calendar days from the receipt of the redetermination.

Non-affirmative decisions often happen because:

  • Documentation is missing or incomplete.
  • The order is missing or incomplete.
  • There is a same or similar device on file.

Resources to help you avoid common errors:

Published: 03.09.2026

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