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Popular:

80.7%

of appealed 2024 Medicare Advantage prior-auth denials were overturned in whole or part

levels in the Medicare Advantage appeal process

one-time appeal-letter package; no subscription

SOURCE: KFF ANALYSIS OF 2024 CMS MEDICARE ADVANTAGE DATA · METHODOLOGY

Notice of Adverse Benefit DeterminationPG 1/2

Dear Member Name,

After review, we have determined that the requested service, MRI, lumbar spine (CPT 72148), is not medically necessary under your plan’s coverage criteria. Your physician’s request has been denied.

You have the right to appeal this decision within the filing deadline shown below . Follow the appeal instructions on this notice…

Start with the facts on your notice.

Three moves. One of them is free.

Built for the moment the envelope arrives, when you’re stressed, on a deadline, and outgunned.

STEP 1

Explain my denial FREE

Answer a few questions from the notice. Get the governing appeal route, the facts still missing, and where to file next.

STEP 2

See the data

Coverage Rights rollups of insurer denial and overturn rates from required public disclosures and state review records.

STEP 3

Generate my appeal $9

A complete, cited appeal package with the data on your side, formatted for your plan type.

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Know your ground first

Insurer denial ratesCoverage Rights rollups and publisher-reported rates from required insurer disclosures.Outcomes by treatment42,000+ published review decisions: how often denials for drugs, imaging, mental health, and more get overturned.Outcomes by conditionFrom cancer to Crohn's: how denial fights ended for patients with your condition.Your appeal rightsMedicare Advantage, employer plans, marketplace, Medicaid — deadlines and escalation ladders.Original Medicare appealsThe 120-day MAC redetermination route for Part A and Part B claim decisions.Medicare Part D drug appealsFormulary exceptions, plan redetermination, expedited review, and the federal appeal ladder.Denial reasons decodedWhat “not medically necessary” actually means, and the counter-strategy for each denial type.Migraine, CGRP & Botox denials993 distinct California reviews across migraine, Ajovy, Emgality, gepants and Botox—with the denominator limits made explicit.Behavioral-health levels of careResidential, PHP, IOP, inpatient and withdrawal-management denial evidence, with TMS kept in its own treatment lane.