My insurer used AI to deny my claim. Can I fight it?
Yes, and the way to fight it is the same as any denial with two additions: ask in writing which tool or criteria produced the decision and who reviewed it, and cite the rules that require an individual clinical judgment. Medicare Advantage plans cannot rely solely on an algorithm, and California requires a physician to make medical-necessity denials.
What to do, in order
- Step 1
Demand the basis and the reviewer
Ask for the internal rule, guideline, protocol or tool relied on and the name and specialty of the health professional who made the decision. On employer and ACA plans these must be provided free on request.
- Step 2
Cite the individual-review requirement
Medicare Advantage: 42 CFR 422.101(c)(1)(i) requires medical-necessity determinations to be based on the individual's circumstances, and CMS has said an algorithm alone cannot be the basis. California: SB 1120 requires that a licensed physician make any medical-necessity denial, modification or delay.
- Step 3
Put the clinical record in front of a human
A letter of medical necessity addressed to the criteria, plus a request for peer-to-peer review, forces a clinician to engage with the specific facts.
- Step 4
Use external review
The independent reviewer is not the plan's tool. Medical-necessity denials are within the scope of external review, and the decision binds the plan.
The deadline that applies
The same clocks as any denial: at least 180 days to file an internal appeal on employer and ACA plans; the plan's reconsideration window on Medicare Advantage (42 CFR 422.582). Ask for expedited handling if waiting would jeopardise your health.
Calculate your date →Documents to gather
- The denial letter or Explanation of Benefits, every page
- Your insurance card and the plan's summary of benefits or Summary Plan Description
- The clinical notes and test results that support the service
- A letter of medical necessity from the treating clinician, written to the plan's criteria
- Your written request for the tool, criteria and reviewer identity, and the plan's answer
Go deeper
Related questions
How do I know AI was used?
Often you do not. Ask directly in the claim-file request: 'Identify any automated tool, algorithm or predictive model used in this determination and the person who reviewed its output.' Silence or a non-answer is worth noting in the appeal.
Is it illegal for an insurer to use AI?
No. The rules govern how decisions are made, not the software. The requirement is an individualised determination by a qualified reviewer, and disclosure of the criteria on request.
Should I complain to the regulator?
Yes, alongside the appeal. State insurance departments and CMS (for Medicare Advantage) track these complaints, and a regulator inquiry often gets the file a second look.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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