Both of these articles are behind paywall. Thanks to Seth for these references.

• WSJ, 2/12/25. Julie Wernau: Health Insurers Deny 850 Million Claims a Year. The Few Who Appeal Often Win.
• Related article: WSJ, 2/12/25, Julie Wernau and Anna Wilde Mathews: Five Steps to Take if Your Health-Insurance Claim Is Denied

Excerpt from first article:

“Health insurers process more than five billion payment claims annually, federal figures show. About 850 million are denied, according to calculations by appeals company Claimable, based on data from health-policy nonprofit KFF and the Centers for Medicare and Medicaid Services. Less than 1% of patients appeal.

Few people realize how worthwhile those labors can be: Up to three-quarters of claim appeals are granted, studies show…”

The author then details how one man overcame a denial to receive a life-saving liver transplantation and how a family helped their child receive immunoglobulin therapy for her neurologic condition. However, this only occurred after numerous appeals and after letters to the Georgia governor and Georgia attorney general.

Excerpts from the second article:

“Here are five things you can do to appeal a denied health-insurance claim.

1. Read up

Know what your plan covers. A good place to start is the summary of benefits and coverage. More detailed information should be available from your employer or insurer, which can provide a more in-depth document sometimes called the “evidence of coverage.” Check to make sure a denial met your insurer’s own rules. These policies are generally available online.

2. Take note

Log dates of calls to your insurer and whom you spoke to. Save paperwork including billing codes for denied services. And act quickly: Insurers have deadlines to file appeals.

3. Fight back

Call your insurer at the number on the back of your insurance card and ask why treatment wasn’t covered. You can ask how to file an appeal. If you have a denial or explanation of benefits letter, look for the section explaining appeals.

4. Get help

State assistance programs and nonprofits including the Patient Advocate Foundation and the Medicare Rights Center can help craft appeals. A startup called Claimable is trying to use technology to smooth the process. You can hire an advocate, looking through a directory or a third-party company, Solace Health. The nonprofit Dollar For helps with hospital bills. You can also ask your doctor’s office or hospital to appeal for you, and try to ensure they keep you in the loop on their communications.

5. Escalate

After you determine why your insurer denied a claim, you can write a letter explaining why the rejection wasn’t warranted. Your doctor can write a letter explaining why care is medically necessary. Pertinent medical studies can strengthen your case. Request the “designated record set” relevant to your case.

If your appeal is rejected, you can often appeal to a higher authority within the insurer. If that fails, you can generally appeal to a third party, often an independent review organization or a government-administered program. Your rejection letter or state insurance department should explain those steps. Practices vary state by state. You can also escalate your appeal to an administrative law judge.”

Related blog posts:

• “Denials, Dilly-dallying and Despair” This post has a lot of useful information on practical steps to appeal denials.
• NY Times: ‘What’s My Life Worth?’ The Big Business of Denying Medical Care
• Mark Cuban: Disrupting American Healthcare
• AI Skirmish in Prior Authorizations
• What’s Changing in IBD Care: Hospitalization Rates and Authorizations
• High Rates of Denying Medical Care for Medicaid Patients Managed by Health Insurers
• IBD Updates: Insurance Barriers Hindering Care, Guselkumab vs Ustekinumab, IBD Pain Management Guidelines
• The Consequences of Prior Authorizations
• FDA IBD Workshop -Take-Home Points Off-label does not equate to experimental FDA Statement: The FD&C Act does not, however, limit the manner in which a physician may use an approved drug. Once a product has been approved for marketing, a physician may prescribe it for uses or in treatment regimens or patient populations that are not included in approved labeling. Such “unapproved” or, more precisely, “unlabeled” uses may be appropriate and rational in certain circumstances, and may, in fact, reflect approaches to drug therapy that have been extensively reported in medical literature
• “We Need More Information to Process This Claim” | gutsandgrowth