Insurance Denial
Intelligence
Insurers denied 20% of 2024 ACA marketplace claims, but fewer than 1% of denied in-network claims were appealed. KFF data shows medical necessity was only 5% of reported in-network denial reasons — documentation and plan rules are usually where appeals win.
19%
Of 2024 ACA marketplace in-network claims denied (KFF)
<1%
Of denied in-network claims are appealed (KFF)
23+
US insurers analyzed with denial-pattern playbooks
Sources: KFF (2024), AMA Prior Authorization Survey (2024), HHS OIG Medicare Advantage Appeal Outcomes (2022). Rates are aggregate averages — individual results vary based on denial type, insurer, and documentation.
Playbooks
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Denial patterns, appeal strategies, known weaknesses — researched per payer.
Categories
Why claims get denied.
The most common reasons insurers say no — and what each one really means for your appeal.
Medical Necessity
Service deemed not medically necessary
Experimental/Investigational
Treatment considered experimental
Out of Network
Provider not in plan network
Prior Authorization
Required prior authorization not obtained
Not Covered
Service not covered under plan
Timely Filing
Claim filed past deadline
Duplicate Claim
Claim considered a duplicate
Coding Error
CPT/ICD coding mismatch
Incomplete Documentation
Missing required documentation
Formulary
Drug not on formulary
Step Therapy
Must try other treatments first
Benefit Exclusion
Explicitly excluded by plan
Coordination of Benefits
Other insurance should pay
Administrative
Administrative/procedural issue
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Upload Your Denial — FreeThis information is for educational purposes based on publicly available data including CMS reports, state insurance department filings, and published insurer guidelines. It does not constitute legal, medical, or financial advice. Individual results vary. Statistics are industry averages and do not represent Lysco-specific outcomes.