News: Insurance denials overturned at high rates by independent review experts, analysis says

Appeals of health insurance claim denials resulted in overturned decisions between 30% and 78% of the time when the case reached independent review organizations (IROs), found by an analysis from completed external appeals.

Out of 51,394 closed cases in New York state from May 31, 2019, to December 10, 2025, almost half (46.7%) of external appeals were overturned at the third level of appeal. This stage often involves independent physicians and other specialists, Joseph Dov Bruch, PhD, of the University of Chicago, and colleagues reported.

In New York state, this level often involves the patients, their physicians, and other caregivers writing multiple letters. After the insurance plan or company issues an initial review and denial, it can be appealed to a second level—an internal appeal review—which is also conducted by the insurance company. If that is denied, the claim goes to the IRO, which can then overturn in whole or in part. There are three IROs certified by New York state law to conduct external reviews, which include board certified physicians and other providers.

Of the 6,469 denied home healthcare services claims that were appealed, 78.4% were overturned when clinical experts not affiliated with the insurance company examined the rationale. The IRO overturned more than half of surgical services, dental or orthodontic procedures, and pharmacy or prescription drug denials.

When analyzed according to diagnosis, researchers found the following:

• Denied care for substance abuse treatments or mental health services was overturned 61% and 60.6% of the time, respectively.
• Central nervous system or neuromuscular disorder denials were overturned 53.1% of the time, and endocrine, metabolic, and nutritional denials were overturned 52.1% of the time.
• Cancer denials were overturned 45.1% of the time.

The analysis tabulated IRO overturn rates by specific named health plan or insurance company. It found that Centers Plan for Healthy Living denials were overturned at the IRO level 85% of the time while 51.1% of Aetna denials, 50% of Excellus denials, 49.8% of CVS Caremark denials, 48.3% of Fidelis Care denials, and 43.1% of Anthem Blue Cross Blue Shield denials were reversed. The researchers only looked at overturned claims in New York because the state data includes names of specific insurance companies. Other states may have the same data but are not as granular.

“We show across the board that the external appeal overturn rate is quite high, but that there definitely is a distribution,” said Bruch. “Consumers have a major opportunity to pursue these types of independent reviews after they exhaust the internal review.”

The researchers stated that their assumption was that the reversal of the denial was the appropriate decision and the denial was incorrect. “It's possible more information is provided" during the IRO review, Bruch said. However, it is also possible that health plan reviewers may be “more discriminatory toward certain types of settings or diagnoses” or treatment protocols they don't approve, he added.

Detailed data about denials can be “leveraged by regulators to identify specific health services, populations, or plans with denial practices that warrant closer scrutiny,” the researchers wrote. Denials can result from a variety of issues, such as human or technical errors, outdated claims systems, ambiguity in coverage rules. But it can also result from “inappropriate insurer behavior -- and thus require different remedies.”

Editor’s note: To read the full report, click here. To read additional coverage by MedPage Today, click here.