Dive Brief:
- More claims denials are being overturned upon appeal, according to a new study, amid widespread public animus against the insurance industry for what many view as overly aggressive restrictions on care.
- In the state of New York, the percentage of denials that were overturned after patients or their physicians appealed increased from 38% in 2019 to almost 53% in 2025, the study published in JAMA on Monday found.
- The rate at which analyzed claims were overturned varied significantly by type of claim and other factors, and denials could be due to a number of reasons, including human error, outdated clinical criteria or inappropriate behavior on the part of payers. Still, rising overturn rates suggest that insurers’ coverage review systems might not be working as intended, and policymakers should consider getting involved, study authors said.
Dive Insight:
Insurers are currently under a harsh spotlight for business practices that can prevent patients from getting care or saddle them with the bill for services. Though insurers argue these processes are a necessary evil to curb inappropriate spending, they can also contribute to administrative burnout for providers and worse outcomes or rising medical debt for patients.
Payers say they’ve taken steps to pare back restrictive care reviews. But providers report that claims denials are increasing, corresponding with growing insurer uptake of algorithmic tools and artificial intelligence to review claims en masse.
Data is sparse on specific insurers’ denial rates. But a number of studies document high denials in specific programs — findings that are especially concerning in light of how many of those denials are overturned upon appeal, suggesting that care should have been approved in the first place.
In the privatized Medicare Advantage program, for example, few beneficiaries actually appeal coverage denials. But for those who do, more than 80% of those denials are eventually overturned, according to health research firm KFF.
For the new study, researchers with Brown University, the University of Texas at San Antonio and the University of Chicago wanted to get a more comprehensive picture of the success of appeals across multiple insurance programs. They analyzed about 51,000 cases from the state of New York, and found rising levels of appeals — and decisions overturned upon appeals — over the study period.
Overturn rates varied heavily by type of treatment, patient diagnosis, insurance company and other factors. For example, more than 78% of denials for home healthcare were overturned upon appeal, while more than 50% of denials for prescription drugs or dental procedures were overturned upon appeal, the study found.
Rates of claims denials overturned upon appeal also differed by insurer, ranging from about 36% for Metroplus Health Plan to 85% for Centers Plan for Healthy Living. Major for-profit insurers like Elevance’s Anthem subsidiary, UnitedHealthcare and CVS’ Aetna all had overturn percentages of about 40% to 50%.
The study didn’t delve into the underlying drivers of the different overturn rates. Researchers also stressed that the study had significant limitations, such as being specific to New York and not including data on all denials in the state.
However, “increasing case volumes and overturn percentages signal that upstream oversight may not be functioning as intended,” researchers wrote, urging patients and clinicians to “consider pursuing external appeals giving the high overturn percentage.”
For years, Congress has considered reforms to limit insurer practices that critics say are driving inappropriate denials, such as prior authorizations in Medicare. However, the changes have failed to make it into legislation, including those in a health package included in the government funding deal earlier this year.
Still, interest in cracking down on some of major insurance companies’ less-popular business practices has persisted on the Hill.
