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The letter you have
Coverage denials, claim rejections, authorization refusals, in-network disputes — insurers deny legitimate claims millions of times every year. Most people accept the denial. The ones who appeal — win far more often than they expect.
At stake: $1,000 – $100,000+
What we do with it
We read the letter. We explain it in plain English. In about 30 seconds you’ll know where you stand — and what to do next.
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Under the Affordable Care Act and ERISA, every adverse benefit determination is appealable. Your insurer must provide a written explanation of the denial, the clinical criteria applied, and your full appeal rights — including the right to external independent review. Most people never know they have these rights until someone tells them.
A score above 70 means you have a solid case worth pursuing. A score of 90 or higher — which we see frequently in cases where the insurer's stated reason is directly contradicted by your clinical record — means the denial has a real error that a reviewer must address. In those cases, fighting back isn't just possible. It's likely to work.
17% claims denied annually · <0.1% ever appeal · 40–60% of appeals succeed
These are the most searched and most successfully appealed health insurance denials. Each one has clear legal and clinical grounds to challenge.
Not Medically Necessary · CO-50
"This claim has been reviewed and determined to be not medically necessary under our clinical coverage criteria. Code CO-50 has been applied."
Why it overturns: CO-50 denials are based on automated clinical criteria reviews that frequently miss the full picture of your medical history. The insurer's reviewer never spoke with your physician. They applied proprietary guidelines — from companies like Milliman or InterQual — that may differ from the standards your physician follows. The most effective appeals cite the specific clinical criteria the reviewer applied and demonstrate, with your physician's documentation, how your case meets or exceeds those criteria. Cases where the insurer's stated reason is directly contradicted by the clinical record — for example, claiming conservative treatment was not attempted when your records show it was — are among the strongest appeal cases ClaimCompass handles.
Emergency Care & Out-of-Network
"Your claim has been processed at the out-of-network benefit level. You are responsible for the balance between our allowable amount and the provider's billed charge."
Why it overturns: The No Surprises Act, effective January 1, 2022, prohibits balance billing for emergency services at any facility and for out-of-network providers at in-network facilities who treated you without your knowledge or consent — including anesthesiologists, radiologists, and assistant surgeons. If any of these situations apply, the insurer cannot charge you more than your in-network cost-sharing, regardless of the provider's network status. Most people who receive surprise bills never know this federal protection exists. An appeal citing the No Surprises Act and the specific circumstances of your care has strong grounds in most situations.
Prior Authorization Denied
"Your request for prior authorization for [procedure] has been denied. The clinical information provided does not support medical necessity under our coverage criteria."
Why it overturns: Prior authorization denials are based on clinical reviewers who never examined you and frequently applied criteria designed to minimize cost rather than reflect your clinical picture. The most powerful tool in a PA appeal is the peer-to-peer review — a direct conversation between your physician and the insurer's medical reviewer. Many PA denials are reversed during peer-to-peer before a formal written appeal is even filed. Request it immediately. If peer-to-peer does not resolve the denial, a formal written appeal citing your clinical history, the FDA-approved indications for the procedure, and the specific clinical criteria your insurer applied is the next step.
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