# The Apellica External Review Index: A Working Map of State External-Review Reversal Rates

**Methodology document — version 1.0 (released 2026-05-19)**

**Maintainer:** Apellica
**Byline:** Mark Henderson
**Reviewed by:** Apellica senior review desk
**License:** Creative Commons CC-BY-4.0

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## What this dataset is

The Affordable Care Act gave every American with a fully-insured plan the right to ask a state-licensed Independent Review Organization (IRO) to re-decide a denial after the insurer's own internal appeal process is exhausted. The reviewer is independent; their decision is binding on the insurer.

The catch: how often that external reviewer sides with the patient is **wildly different** depending on which state you live in.

This dataset is the first comprehensive 2026 attempt to assemble what each state's own Department of Insurance (or equivalent) publishes about their external-review program, in one place, with every number anchored to a verifiable public-record URL.

It is built **entirely from public-record state Department of Insurance annual reports, state legislative reports, and CMS data**. Apellica's proprietary case-level data is **not** included. This is a public-record dataset for journalists, researchers, policymakers, and patient-advocacy groups.

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## What the columns mean

| Column | Definition |
| --- | --- |
| `state` | Full jurisdiction name |
| `state_abbrev` | USPS or ISO 3166-2 code |
| `year` | Most recent year for which we located a published statistic |
| `regulator_name` | Department of Insurance or equivalent regulator that administers the program |
| `regulator_url` | Home page of the regulator |
| `total_external_reviews` | Total external-review cases initiated, decided, or completed (per the state's definition) |
| `total_overturned_full_or_partial` | Cases where the insurer denial was reversed in whole or in part by the IRO |
| `percent_overturned` | Decimal share of completed cases overturned in full or part |
| `system_type` | `state-run` (NAIC-parallel) or `HHS-administered` (federal MAXIMUS process) |
| `source_document` | The single URL most directly supporting the data point |
| `notes` | Caveats, year-coverage notes, divergent definitions, data gaps |

Empty cells are **deliberately empty** when the underlying state has not published the underlying number. We do not extrapolate or estimate.

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## What we did not do

1. **We did not invent numbers.** If a state does not publicly post a current overturn count or rate, that state's data cells are empty and its `notes` cell explains the gap.

2. **We did not roll up to a single national average.** The denominators are not comparable across states — some count cases received, some count cases completed, some count completed-and-eligible. The KFF historic landmark figure (~45% nationwide average, range 21% Arizona to 72% Connecticut) is referenced but not used as a current-year input.

3. **We did not split out cancer / oncology subsets.** This dataset is the general external-review universe.

4. **We did not include workers' compensation.** California's DIR / DWC publishes a separate workers' comp IMR report. Only DMHC's commercial / public-program IMR is referenced for California in this dataset.

5. **We did not include Medicare Advantage Independent Review Entity (IRE) data.** Federal Medicare appeal data is published separately by CMS via the Part C IRE contractor (also MAXIMUS), and the overturn dynamics are materially different (recent CMS data cites MA appeal overturn rates around 82%).

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## Data-quality flags inside the CSV

We tagged five distinct categories of caveat in the `notes` column:

1. **HHS-administered.** State has no compliant state-run external-review system for federally regulated plans; cases route to MAXIMUS Federal Services. CMS does not publish jurisdiction-level case totals for the federal process, so these rows have empty count fields by design. The KFF 2024 classification lists Alabama, Florida, Georgia, Texas, and Wisconsin in this category, plus four U.S. territories (American Samoa, Guam, Northern Mariana Islands, U.S. Virgin Islands).

2. **Cumulative-period rate, not single-year.** Some figures (Kansas ~54% since 2018; West Virginia ~17% over last 5 years) are multi-year cumulative rates the regulator publishes that way. Flagged in `notes`.

3. **Broader-than-IRO reversal rate.** Two states (California, Maryland) publish a "reversed/modified by the regulator's complaint-handling pathway" figure that is broader than the strict IRO-only overturn rate — it includes pre-decision insurer concessions and complaint-process reversals. Flagged in `notes`. For California we also include the narrower 12.7% IMRO-only treatment-denial overturn rate so readers see both.

4. **Methodology divergence flagged in the CSV row.** Texas IRO data is structurally different from California DMHC IMR data — Texas certifies IROs and posts individual decisions; California's DMHC pools through a single contracted IMRO (MAXIMUS Federal Services). They should not be compared digit-for-digit.

5. **Data gap — regulator does not publish.** Where a state's DOI does not currently publish discoverable external-review statistics, that row carries empty count fields and the `notes` cell calls it out. This is the single largest finding of the exercise — **transparency itself is the lottery**.

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## Where we got each state's data (sources by state)

For each non-gap row, the `source_document` column gives the single most-load-bearing URL. The full list of regulator home pages is in the `regulator_url` column. Additional cross-checks used:

- **NBC News, "Insurance denied an $800,000 drug twice..."** (2025) — multi-state aggregator that cited NC Smart NC at 53%, Kansas 54%, Colorado 44%, California 51% (10-yr), South Carolina 43%, Washington 25%, West Virginia 17%. https://www.nbcnews.com/health/health-news/insurance-denied-800000-drug-twice-state-run-panel-helped-north-caroli-rcna248068
- **KFF (Kaiser Family Foundation), "Claims Denials and Appeals in ACA Marketplace Plans in 2024"** — national ACA marketplace data; 5,881 external appeals filed in 2024, ~half overturned nationally. https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/
- **KFF, "State External Appeals Review Processes"** — state classification (state-run vs HHS-administered). https://www.kff.org/affordable-care-act/state-indicator/external-appeals-review-processes/
- **CMS / CCIIO HHS-Administered Federal External Review Process** — list of HHS-administered jurisdictions and MAXIMUS portal. https://www.cms.gov/cciio/programs-and-initiatives/consumer-support-and-information/csg-ext-appeals-facts
- **ProPublica, "How to Fight Your Health Insurance Denial With an External Appeal"** — corroborates Connecticut 80%. https://www.propublica.org/article/health-insurance-denial-external-review

Every state row's most authoritative source is the state regulator's own report URL.

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## Headline findings (as of 2026-05-19)

### States that publish current-year case-level data (count + outcome)

Five jurisdictions cleanly publish both a denominator and an outcome breakdown:

| State | Year | Total reviewed | Overturned (full or part) | Overturn rate |
| --- | --- | --- | --- | --- |
| Oregon | 2025 (through 2025-06-30) | 278 (completed) | 108 | 38.85% |
| Pennsylvania | 2024-25 cumulative | 1,353 | 655 | 48.4% |
| North Carolina (Smart NC) | 2024 (through Nov) | 282 | 153 | 54.3% |

A second tier publishes a current overturn rate but not a cleanly attributable case denominator: California (DMHC: 73% all-pathways success / 12.7% strict IMRO treatment overturn 2024), Maryland (MIA: 66.8% reversed-or-modified 2024), Connecticut (Healthcare Advocate: ~80%), Minnesota (Department of Commerce: 43% in 2024), Colorado (DORA: 44% in 2024), Massachusetts (OPP: ~40% in 2023), South Carolina (43% in 2024), Kansas (54% cumulative since 2018), Washington (25% in 2024), West Virginia (17% over 5 years).

### The single most important finding: transparency is the lottery

Of 56 jurisdictions surveyed (50 states + DC + Puerto Rico + 4 U.S. territories), **fewer than 20 publish a verifiable, current-year overturn statistic** for their general external-review program in a form a journalist or patient can find in under 10 minutes of searching. Five states (Alabama, Florida, Georgia, Texas, Wisconsin) use HHS-administered federal review, and CMS does not publish jurisdiction-level statistics from that process either. The rest — including large states like Illinois, Michigan, New Jersey, Ohio, Virginia, Indiana — either don't publish current external-review tabulations at all, or bury them in binary PDF annual reports that are not machine-readable.

A patient asking "what are my odds of winning if I appeal in my state?" cannot get a defensible answer in 27 of 50 states.

### Where the variance lives

Where current numbers do exist, the public-record range is **17 percent (West Virginia, 5-year) to ~80 percent (Connecticut, with patient-advocate involvement)** — a 4.7x spread for what is supposed to be the same federally guaranteed appeal right.

The KFF historic study (1999) found a 21%-72% range across states. **A quarter century later, the variance has not narrowed.**

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## How to use this dataset responsibly

- **For journalism:** Each row's `source_document` URL is the citation. If you cite an overturn rate, link the source URL. Do not aggregate to a national figure across states with divergent definitions.
- **For research / academic citation:** Cite the dataset version (1.0, 2026-05-19), the source URLs in the row, and link this methodology document.
- **For patients:** Use the dataset to understand the order-of-magnitude probability in your state, but always file the appeal — even in the lowest-overturn jurisdiction in this dataset (West Virginia at 17%), a one-in-six chance of free coverage of a denied service is a strong expected-value bet.

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## Future updates

Apellica will refresh this dataset quarterly. Sources that publish updates (Oregon's IRO Case Detail Report, California's DMHC open-data trend file, New York's DFS Appeal Explorer, Pennsylvania's PID press updates) feed forward automatically. State-level data gaps will be re-checked each cycle and reduced where regulators newly publish.

A public GitHub mirror and Zenodo DOI of this dataset will follow within 7 days of this initial release. The CC-BY-4.0 license permits any reuse with attribution to "Apellica, *The Apellica External Review Index*, v1.0, 2026."

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## Contact

Press: press@apellica.com
Data corrections / source additions: data-corrections@apellica.com

Apellica
*The Apellica External Review Index* — version 1.0 — 2026-05-19