How Apellica builds an insurance appeal.
The carrier denied your claim under the authority of a written medical-policy bulletin. The federal appeal rules give you the right to read that bulletin, to receive the criteria the carrier applied, and to demand the carrier follow its own published rule. Apellica reads the bulletin for a living. The patient is reading one bulletin under deadline pressure. The four pillars below are how we close that gap.
Every Apellica appeal stands on the same four pillars.
Carrier medical-policy bulletin mapping.
Every appeal we file is built around the carrier's own published medical-policy bulletin (UnitedHealthcare, Aetna, Anthem/Elevance, Cigna, Humana, Kaiser, BCBS state licensees). We pull the operative bulletin by CPT or HCPCS code, identify the version date, and pair every clinical criterion with a citation from the patient's medical record. The result is a criteria-met paragraph that maps the carrier's own rule to the documented facts, line by line.
Federal regulatory grounding.
Each appeal cites the controlling federal authority for the plan type. ERISA self-funded plans: 29 CFR 2560.503-1 and ERISA 104(b) for plan-document disclosure. ACA marketplace and individual plans: 45 CFR 147.136 for internal and external review. Medicare Advantage: 42 CFR 422 Subpart M for reconsideration. Medicare Original: redetermination through the MAC. Medicaid managed care: 42 CFR 438 Subpart F. We name the section and the right.
State external-review program routing.
Every state and DC operates an external-review program with its own statute, deadline, and DOI complaint channel. Apellica maintains a current map of all 51 jurisdictions, including the federal HHS-administered backstop available to consumers in states that opted out. When internal appeal is denied, we route to the right external IRO and DOI escalation path the first time, on the correct form.
Bulletin-lag evidence stack.
Medical-policy bulletins update on twelve to thirty-six month cycles. FDA labeling and specialty-society guidelines update faster. Where a bulletin has fallen behind current evidence, we file a second-order argument citing the bulletin's own evidence framework against the current guideline version. The carrier is bound by the framework it published.
Eight steps from denial letter to filed appeal.
Triage and routing.
A senior reviewer reads the denial letter, identifies the controlling plan type (ERISA, ACA, MA, Medicare Original, Medicaid managed care), the controlling federal authority, the state external-review program, the carrier's bulletin library, and the appeal deadline. Routed to the right specialist queue.
Document request under federal authority.
Where the denial letter cites a policy bulletin the patient was not given, we send a document-request letter citing 29 CFR 2560.503-1(h)(2)(iii) (ERISA) or 45 CFR 147.136(b)(2)(ii)(C) (ACA). The carrier has 30 days to produce the operative bulletin. A carrier that does not respond is procedurally vulnerable.
Criteria-met paragraph drafted.
Each enumerated criterion in the bulletin is paired with a chart note, lab result, imaging report, or prior-treatment record. Compound criteria (joined by 'and') are addressed in full. Duration and trial requirements are documented by date. Exclusionary conditions are explicitly attested absent.
Four-part evidence stack assembled.
Plan-language citation. Criteria-met paragraph mapped to the medical record line by line. Peer-reviewed evidence at the carrier's stated evidence tier. Regulatory hook (CFR or USC) appropriate to the plan type.
Bulletin-lag analysis where applicable.
Where current FDA labeling or specialty-society guidelines have outrun the carrier's bulletin, we cite the newer guideline version, document the version date, and request the reviewer apply the bulletin's own evidence framework to the current literature.
Senior review and patient sign-off.
Every appeal is read by a senior reviewer before it leaves. The patient sees the final letter, the criteria-met paragraph, and every cite. Nothing is filed without the patient's written approval.
Filing on the correct channel.
The appeal is filed by the channel the carrier requires: portal, fax, certified mail. The filing receipt is captured. The patient's case portal shows the filing reference within 24 hours.
Escalation if denied.
If internal appeal is denied, we route to peer-to-peer review or external review on the right state form, before the deadline. Where the carrier stalled or denied procedurally, we file a parallel complaint with the state Department of Insurance.
What we are. What we are not.
Reviewed by counsel.
Methodology is reviewed against current ERISA case law and the most recent NAIC External Review Model Act. We do not provide legal advice, and we are not your attorney. Where a case requires litigation, we refer to outside counsel.
HIPAA-aligned data handling.
TLS 1.3 in transit. AES-256 at rest. Business Associate Agreement available on request. Access to identifiable patient health information is restricted to the senior reviewer assigned to the case and the carrier-facing dispatch worker. We do not train AI on identifiable PHI.
No fabricated win rates.
We do not publish a portfolio win rate. Outcomes vary by denial archetype, plan type, carrier, jurisdiction, and the strength of the underlying medical record. Historical results across a portfolio do not predict any individual case.
Scope discipline.
Apellica does not accept oncology, cancer-treatment, or rare-disease claims. Visitors with those denials are referred to their state external-review program and the Patient Advocate Foundation. We turn cases away when an appeal is unlikely to be productive and we say so clearly.
Send us your denial letter.
A senior reviewer reads it within 24 hours and tells you, in writing, whether it is appealable, on what grounds, and what evidence will move the carrier. No card required. You only pay if we win.