What we've learned navigating denials.
Tactics, denial-code playbooks, and the patterns we see across 50+ carriers. Honest, specific, no fluff.
Why fewer than 1% of denied claims are ever appealed
The system depends on patients accepting the first answer. Here is how that pattern got built and why it works on almost everyone.
GLP-1 denials (Wegovy, Ozempic, Zepbound): what actually flips them
BMI thresholds, T2D pathways, formulary exceptions. The three angles that win most GLP-1 appeals, and the one that wins them faster.
Medicare Advantage has five appeal levels. Most people stop at one.
Level 1 reverses 41%. Level 2 (Maximus) reverses higher. Level 3 (ALJ) is where the real wins happen. Here's the full ladder.
What a winning appeal letter actually contains
Appeals aren't pleas. They're rebuttals. Five things every winning letter has, and the one phrase that does most of the work.
Prior authorization: the denial that isn't really a denial
Most 'denials' are actually prior-auth refusals, and there's a separate, faster path to reverse them. Most patients don't know it exists.