What a strong case can look like
Illustrative examples of what makes a denial, bill, surprise charge, or prior-auth case worth fighting — and what evidence each one needs.
The scenarios below are fictional educational examples, not Lysco customer results or outcome predictions. The one statistic on this page comes from KFF's analysis of 2024 HealthCare.gov claims data; the full citation is on our research page. Nothing here is medical or legal advice.
Illustrative scenarios
How different cases might be organized
Fictional examples for education only. The amounts, locations, and timelines below are not customer results or predictions.
Texas: $12,400 at issue for knee surgery authorization
Example approach: A response could pair the plan criteria with the orthopedist's recommendation and supporting clinical records.
Florida: $3,200 at issue for hospital billing errors
Example approach: An itemized-bill review could flag duplicate lab entries and ask the provider to validate the facility fee.
Ohio: $2,840 at issue for outpatient procedure billed over the estimate
Example approach: A line-by-line comparison could show whether the bill exceeds the Good Faith Estimate enough to qualify for federal dispute review.
Illinois: $1,850 at issue for out-of-network anesthesiologist charge
Example approach: A review could check whether federal surprise-billing protections apply to an out-of-network clinician at an in-network facility.
Georgia: $8,200 at issue for biologic medication that needed prior authorization
Example approach: A complete request could organize step-therapy history, clinical records, and relevant labeling around the plan's stated requirements.
Michigan: $15,600 at issue for outpatient surgery
Example approach: A response could document the network search and ask whether an in-network exception is available.