Denial & Appeals
Review authorization denials, manage appeal workflows, and track overturn outcomes
Total Denials (MTD)
43
Appeals Pending
17
Overturn Rate
38%
Upheld
27
Denial List
| Auth ID | Patient | Service | Date | Reason | Level | Actions |
|---|---|---|---|---|---|---|
| PA-2024-0411 | M. Santos | Cardiac Cath | Apr 1 | D001 — Not Med Nec | L1 | |
| PA-2024-0398 | J. Okafor | MRI Lumbar | Mar 30 | D002 — Alt Tx Req'd | L2 | |
| PA-2024-0385 | L. Zhao | Spinal Fusion | Mar 28 | D003 — Not Covered | IRO | |
| PA-2024-0374 | R. Chen | Hip Replacement | Mar 25 | D001 — Not Med Nec | L1 | |
| PA-2024-0361 | P. Adams | GLP-1 Rx | Mar 22 | D004 — Step Therapy | L1 | |
| PA-2024-0349 | D. Kumar | Chemo Infusion | Mar 20 | D005 — Site of Care | L2 | |
| PA-2024-0336 | S. Miller | PT x 20 visits | Mar 18 | D006 — Freq Exceeded | L1 |
Denial Reason Breakdown
Overturn Stats
L1 Overturn Rate
42%
L2 Overturn Rate
29%
IRO Overturn Rate
55%
Overall Overturn
38%
Appeal Timeline — PA-2024-0374 (R. Chen)
D
Denial Issued
Mar 25, 2024 — 10:14 AM
Initial denial: D001 — Not Medically Necessary. Hip replacement lacks conservative therapy documentation.
A
Level 1 Appeal Filed
Mar 27, 2024 — 2:30 PM
Appeal submitted by Dr. Martinez with 6 months PT records and X-ray evidence of joint deterioration.
R
Medical Director Review
Mar 28, 2024 — 11:00 AM
Under review by Dr. Jamie Davis. P2P call scheduled for Apr 2.
P
P2P Call Pending
Apr 2, 2024 — 3:00 PM (scheduled)
Peer-to-peer review call between Dr. Martinez and Medical Director.