The data is in, and it confirms what you’ve always suspected: The insurance denial system isn't broken—it’s working exactly as it was designed.

According to the groundbreaking CMS-0057-F data set, the numbers are staggering:

• 80.7% of Medicare Advantage authorization denials are OVERTURNED on appeal.

• That is 4 out of every 5 denials successfully reversed when challenged.

  The "Uncontested" Denial: Data for Employer & Private Plans

  While Medicare Advantage sees an 80.7% overturn rate, the landscape for private employer and ACA plans reveals a different kind of systemic failure:

  • 19% Denial Rate: Insurers in the private and ACA markets denied nearly 1 in 5 in-network claims in 2024.

  • The "One Percent" Problem: Despite the high volume of denials, fewer than 1% of patients in these plans ever file an appeal.

  • The "Silent No": Because 99% of denials go unchallenged, billions of dollars in legitimate medical care are left unpaid every year.

  • Reasoning Gap: Only 5% to 6% of these denials are actually based on "Medical Necessity." The rest are technicalities: 25% are administrative errors, and 36% are categorized as "Other"—vague labels designed to discourage follow-up.

The Silent Tax on Your Health

If 80% of denials are winnable, why are they denied in the first place? Payers systematically deny clean claims, betting on the fact that the process is so slow, expensive, and frustrating that you—and your provider—will simply give up.

And the tactic is working. Currently, only 11.5% of denials are ever appealed. Most providers don't have the staffing or resources to fight for you. They are forced to leave money on the table, and you are left without the care you need.

The Healthcare Hack: Systematic Intelligence for the Patient

Insurance companies use algorithms and restrictive criteria to protect their bottom line. We use federal regulations, CMS standards, and the No Surprises Act to protect yours.

The rules are public. Medicare Advantage plans cannot legally apply criteria more restrictive than CMS standards. We provide the intelligence to surface these violations at the point of appeal.

Don't let a "No" be the final answer. Most denials are winnable.

Ready to Hack the System? Stop leaving your health to chance. Access our specialized appeal blueprints or speak with a concierge advocate to reverse your denial today.