Persius
@persiusorg.bsky.social
Empowering collective action in healthcare through digital tools, data, and patient advocacy. We help people with coverage denials for free.
persius.org
Newsletter:
https://persius.org/newsletter
persius.org
Newsletter:
https://persius.org/newsletter
External appeal overturn rates are supposed to be low. High rates mean internal appeal processes are not working.
The external appeal overturn rate among people with cancer on Managed Long Term Care plans in New York is 85%.
Read the report here:
The external appeal overturn rate among people with cancer on Managed Long Term Care plans in New York is 85%.
Read the report here:
New York Data Suggest Coverage Denials Put Most Vulnerable Patients At Risk
People’s Action Executive Director Sulma Arias condemns Trump’s Senate budget as a violent attack on working families—cutting Medicaid, housing, and food to fund tax breaks for billionaires. The…
peoplesaction.org
November 12, 2025 at 9:01 PM
External appeal overturn rates are supposed to be low. High rates mean internal appeal processes are not working.
The external appeal overturn rate among people with cancer on Managed Long Term Care plans in New York is 85%.
Read the report here:
The external appeal overturn rate among people with cancer on Managed Long Term Care plans in New York is 85%.
Read the report here:
Health insurers go to great lengths to defend the indefensible, because they count on us giving up.
November 12, 2025 at 4:07 PM
Health insurers go to great lengths to defend the indefensible, because they count on us giving up.
If you appreciate our work and are in a position to donate, we are grateful for anything you can give. Link in bio.
We help people appeal coverage denials for free, and have overturned over $600k. We prioritize support for time sensitive, critical care.
We help people appeal coverage denials for free, and have overturned over $600k. We prioritize support for time sensitive, critical care.
November 12, 2025 at 12:43 AM
If you appreciate our work and are in a position to donate, we are grateful for anything you can give. Link in bio.
We help people appeal coverage denials for free, and have overturned over $600k. We prioritize support for time sensitive, critical care.
We help people appeal coverage denials for free, and have overturned over $600k. We prioritize support for time sensitive, critical care.
HHS OIG:
"MAO denied a request for a walker (estimated cost $112) for a 76-year-old beneficiary with post-polio syndrome. The MAO stated that, per its clinical criteria, the beneficiary was not eligible to receive a walker because the beneficiary had already received a cane within the last 5 years."
"MAO denied a request for a walker (estimated cost $112) for a 76-year-old beneficiary with post-polio syndrome. The MAO stated that, per its clinical criteria, the beneficiary was not eligible to receive a walker because the beneficiary had already received a cane within the last 5 years."
November 11, 2025 at 3:07 PM
HHS OIG:
"MAO denied a request for a walker (estimated cost $112) for a 76-year-old beneficiary with post-polio syndrome. The MAO stated that, per its clinical criteria, the beneficiary was not eligible to receive a walker because the beneficiary had already received a cane within the last 5 years."
"MAO denied a request for a walker (estimated cost $112) for a 76-year-old beneficiary with post-polio syndrome. The MAO stated that, per its clinical criteria, the beneficiary was not eligible to receive a walker because the beneficiary had already received a cane within the last 5 years."
Each year, there are over 290,000 denials administered in state-regulated commercial health insurance plans in New York for alleged 'lack of medical necessity'.
Many are necessary.
Many are necessary.
November 6, 2025 at 11:01 PM
Each year, there are over 290,000 denials administered in state-regulated commercial health insurance plans in New York for alleged 'lack of medical necessity'.
Many are necessary.
Many are necessary.
Proprietary guidelines are a linchpin of health insurance denials.
Insurers pay doctors to write guidelines. Then they deny coverage, pointing to the guidelines as justification.
We analyze guidelines daily. They mischaracterize, and cherry-pick.
Guidelines should not be developed by insurers.
Insurers pay doctors to write guidelines. Then they deny coverage, pointing to the guidelines as justification.
We analyze guidelines daily. They mischaracterize, and cherry-pick.
Guidelines should not be developed by insurers.
November 6, 2025 at 2:16 PM
Proprietary guidelines are a linchpin of health insurance denials.
Insurers pay doctors to write guidelines. Then they deny coverage, pointing to the guidelines as justification.
We analyze guidelines daily. They mischaracterize, and cherry-pick.
Guidelines should not be developed by insurers.
Insurers pay doctors to write guidelines. Then they deny coverage, pointing to the guidelines as justification.
We analyze guidelines daily. They mischaracterize, and cherry-pick.
Guidelines should not be developed by insurers.
We’re working with someone who is being wrongly denied access to an independent medical review (IMR).
IMR is meant to ensure wrongful denials can be reviewed by independent doctors.
But the very insurers who wrongly deny coverage often determine qualification for IMR. And they often get it wrong.
IMR is meant to ensure wrongful denials can be reviewed by independent doctors.
But the very insurers who wrongly deny coverage often determine qualification for IMR. And they often get it wrong.
November 4, 2025 at 8:10 PM
We’re working with someone who is being wrongly denied access to an independent medical review (IMR).
IMR is meant to ensure wrongful denials can be reviewed by independent doctors.
But the very insurers who wrongly deny coverage often determine qualification for IMR. And they often get it wrong.
IMR is meant to ensure wrongful denials can be reviewed by independent doctors.
But the very insurers who wrongly deny coverage often determine qualification for IMR. And they often get it wrong.
"Our findings suggest that insurers may be targeting specific patient populations via inappropriate denial practices. "
From "Denied: The Harmful Role of Prior Authorization and Claim Denials."
You can read the full report here:
peoplesaction.org/new-york-dat...
From "Denied: The Harmful Role of Prior Authorization and Claim Denials."
You can read the full report here:
peoplesaction.org/new-york-dat...
November 1, 2025 at 7:16 PM
"Our findings suggest that insurers may be targeting specific patient populations via inappropriate denial practices. "
From "Denied: The Harmful Role of Prior Authorization and Claim Denials."
You can read the full report here:
peoplesaction.org/new-york-dat...
From "Denied: The Harmful Role of Prior Authorization and Claim Denials."
You can read the full report here:
peoplesaction.org/new-york-dat...
We regularly see what appears to be AI generated slop in health insurance denials.
These denials have extremely serious consequences for patients, and there needs to be accountability for failing to follow mandated procedure.
These denials have extremely serious consequences for patients, and there needs to be accountability for failing to follow mandated procedure.
November 1, 2025 at 12:49 PM
We regularly see what appears to be AI generated slop in health insurance denials.
These denials have extremely serious consequences for patients, and there needs to be accountability for failing to follow mandated procedure.
These denials have extremely serious consequences for patients, and there needs to be accountability for failing to follow mandated procedure.
Health insurance denials are rarely appealed, but those that are are frequently overturned. This suggests wrongful denials are not sufficiently disincentivized.
Wrongful denials have life threatening consequences for patients, and consequences need to be made correspondingly serious for insurers.
Wrongful denials have life threatening consequences for patients, and consequences need to be made correspondingly serious for insurers.
November 1, 2025 at 12:00 AM
Health insurance denials are rarely appealed, but those that are are frequently overturned. This suggests wrongful denials are not sufficiently disincentivized.
Wrongful denials have life threatening consequences for patients, and consequences need to be made correspondingly serious for insurers.
Wrongful denials have life threatening consequences for patients, and consequences need to be made correspondingly serious for insurers.
Insurers claim ‘insufficient evidence’ for proven treatments while selectively citing only the oldest literature. Then they disregard newer studies demonstrating efficacy.
Who’s gonna break the news that cherry picking literature to support a forgone conclusion is not scientific?
Who’s gonna break the news that cherry picking literature to support a forgone conclusion is not scientific?
October 31, 2025 at 1:16 PM
Insurers claim ‘insufficient evidence’ for proven treatments while selectively citing only the oldest literature. Then they disregard newer studies demonstrating efficacy.
Who’s gonna break the news that cherry picking literature to support a forgone conclusion is not scientific?
Who’s gonna break the news that cherry picking literature to support a forgone conclusion is not scientific?
Absurd denial: patient got doses 1&2 of a 3-dose vaccine. Insurer denied dose 3 because patient allegedly "aged out" mid treatment.
Stupid denial, overturned after a fight.
Insurers go to great lengths to defend the indefensible, because they count on us giving up.
Reach out if you need help.
Stupid denial, overturned after a fight.
Insurers go to great lengths to defend the indefensible, because they count on us giving up.
Reach out if you need help.
October 30, 2025 at 10:01 PM
Absurd denial: patient got doses 1&2 of a 3-dose vaccine. Insurer denied dose 3 because patient allegedly "aged out" mid treatment.
Stupid denial, overturned after a fight.
Insurers go to great lengths to defend the indefensible, because they count on us giving up.
Reach out if you need help.
Stupid denial, overturned after a fight.
Insurers go to great lengths to defend the indefensible, because they count on us giving up.
Reach out if you need help.
In 2020, New York State enacted legislation requiring health insurers to report aggregate claims data to increase transparency in coverage decisions.
The data shows that in 2023, denials overturned through internal appeal processes amounted to over $3 billion in billed charges.
The data shows that in 2023, denials overturned through internal appeal processes amounted to over $3 billion in billed charges.
October 30, 2025 at 1:16 PM
In 2020, New York State enacted legislation requiring health insurers to report aggregate claims data to increase transparency in coverage decisions.
The data shows that in 2023, denials overturned through internal appeal processes amounted to over $3 billion in billed charges.
The data shows that in 2023, denials overturned through internal appeal processes amounted to over $3 billion in billed charges.
Lots of talk about forthcoming health insurance premium hikes. Less talk about how even when people can pay their premiums, coverage they've paid for is regularly withheld through wrongful coverage denials. This belongs in the same conversation, and both are critical fights.
October 29, 2025 at 8:01 PM
Lots of talk about forthcoming health insurance premium hikes. Less talk about how even when people can pay their premiums, coverage they've paid for is regularly withheld through wrongful coverage denials. This belongs in the same conversation, and both are critical fights.
"External appeals serve a unique and critical role in ensuring access to justice for patients facing inappropriate denials. They provide a relatively unbiased, low-barrier pathway for patients to contest denials. In contrast, internal appeals lack a conceptual basis for impartiality."
October 29, 2025 at 3:09 PM
"External appeals serve a unique and critical role in ensuring access to justice for patients facing inappropriate denials. They provide a relatively unbiased, low-barrier pathway for patients to contest denials. In contrast, internal appeals lack a conceptual basis for impartiality."
Reposted by Persius
Losing your health coverage is bad enough. But for hundreds of thousands of workers, it could also mean losing a job.
New research shows the economic damage if enhanced ACA tax credits expire this year.
New research shows the economic damage if enhanced ACA tax credits expire this year.
Expiring ACA Premium Tax Credits Could Lead to Nearly 340,000 Jobs Lost Across the U.S. in 2026
Unless Congress acts quickly to extend the enhanced ACA marketplace premium tax credits, nearly 5 million people could lose health insurance coverage in 2026.
bit.ly
October 20, 2025 at 1:27 PM
Losing your health coverage is bad enough. But for hundreds of thousands of workers, it could also mean losing a job.
New research shows the economic damage if enhanced ACA tax credits expire this year.
New research shows the economic damage if enhanced ACA tax credits expire this year.
Reposted by Persius
Turns out investing in health care leads to better health outcomes! 😱 Who knew?!
Maternal and Child Mortality: How Do U.S. States Compare Internationally?
This brief compares U.S. maternal and child mortality rates at the national, state, and racial and ethnic level to 200 countries.
www.commonwealthfund.org
October 28, 2025 at 4:23 PM
Turns out investing in health care leads to better health outcomes! 😱 Who knew?!
We sometimes speak to regulators who say “they can’t do that!” when we explain the egregious wrongful behavior we witness in individual cases.
We have to explain that: they can do that, they are doing that (regularly), and they will continue doing it while there is minimal enforcement.
We have to explain that: they can do that, they are doing that (regularly), and they will continue doing it while there is minimal enforcement.
October 28, 2025 at 11:43 PM
We sometimes speak to regulators who say “they can’t do that!” when we explain the egregious wrongful behavior we witness in individual cases.
We have to explain that: they can do that, they are doing that (regularly), and they will continue doing it while there is minimal enforcement.
We have to explain that: they can do that, they are doing that (regularly), and they will continue doing it while there is minimal enforcement.
When independent third parties review appeals of Medicare Advantage denials, they find 5% of the denials merit overturn on average.
When they review appeals related to Opioid Dependence, they find 15% merit overturn. For lung cancer, it's 12%.
More here:
blog.persius.org/blog/medicar...
When they review appeals related to Opioid Dependence, they find 15% merit overturn. For lung cancer, it's 12%.
More here:
blog.persius.org/blog/medicar...
Medicare Advantage QIC Appeal Outcomes
We analyze data from the CMS Medicare Part C and D Qualified Independent Contractor appeal database.
blog.persius.org
October 28, 2025 at 6:16 PM
When independent third parties review appeals of Medicare Advantage denials, they find 5% of the denials merit overturn on average.
When they review appeals related to Opioid Dependence, they find 15% merit overturn. For lung cancer, it's 12%.
More here:
blog.persius.org/blog/medicar...
When they review appeals related to Opioid Dependence, they find 15% merit overturn. For lung cancer, it's 12%.
More here:
blog.persius.org/blog/medicar...
"Some patient populations are bearing the brunt of the harms caused by wrongful denials, and these patient populations are often already facing dire circumstances"
From "Denied: The Harmful Role of Prior Authorization and Claim Denials"
Full report here:
peoplesaction.org/new-york-dat...
From "Denied: The Harmful Role of Prior Authorization and Claim Denials"
Full report here:
peoplesaction.org/new-york-dat...
New York Data Suggest Coverage Denials Put Most Vulnerable Patients At Risk
People’s Action Executive Director Sulma Arias condemns Trump’s Senate budget as a violent attack on working families—cutting Medicaid, housing, and food to fund tax breaks for billionaires. The fight...
peoplesaction.org
October 25, 2025 at 6:39 PM
"Some patient populations are bearing the brunt of the harms caused by wrongful denials, and these patient populations are often already facing dire circumstances"
From "Denied: The Harmful Role of Prior Authorization and Claim Denials"
Full report here:
peoplesaction.org/new-york-dat...
From "Denied: The Harmful Role of Prior Authorization and Claim Denials"
Full report here:
peoplesaction.org/new-york-dat...
In NY 91% of health insurance denials for services related to severe asthma attacks that are externally appealed are overturned.
This is a systemic problem. We need meaningful accountability for repeated administration of wrongful denials.
These denials should never be made to begin with.
This is a systemic problem. We need meaningful accountability for repeated administration of wrongful denials.
These denials should never be made to begin with.
October 24, 2025 at 3:03 PM
In NY 91% of health insurance denials for services related to severe asthma attacks that are externally appealed are overturned.
This is a systemic problem. We need meaningful accountability for repeated administration of wrongful denials.
These denials should never be made to begin with.
This is a systemic problem. We need meaningful accountability for repeated administration of wrongful denials.
These denials should never be made to begin with.
In any other profession, we'd call getting the outcome right 48% of the time in critical contexts incompetence.
Insurers should no longer be allowed to be involved in appeals processes. People's lives are on the line
Insurers should no longer be allowed to be involved in appeals processes. People's lives are on the line
October 23, 2025 at 10:02 PM
In any other profession, we'd call getting the outcome right 48% of the time in critical contexts incompetence.
Insurers should no longer be allowed to be involved in appeals processes. People's lives are on the line
Insurers should no longer be allowed to be involved in appeals processes. People's lives are on the line
In California, 52% of external appeals for health insurance denials related to breast cancer are overturned.
Most of these denials were first appealed 'internally', where they were reviewed again by the insurer and again (incorrectly) deemed to be appropriate.
Most of these denials were first appealed 'internally', where they were reviewed again by the insurer and again (incorrectly) deemed to be appropriate.
October 23, 2025 at 10:02 PM
In California, 52% of external appeals for health insurance denials related to breast cancer are overturned.
Most of these denials were first appealed 'internally', where they were reviewed again by the insurer and again (incorrectly) deemed to be appropriate.
Most of these denials were first appealed 'internally', where they were reviewed again by the insurer and again (incorrectly) deemed to be appropriate.
In 2023 we submitted a request to the PA Insurance Department for health insurer denial data from the state.
The request was granted, and we released the data publicly for the first time. Following our release, the state began reporting the data themselves, as was required from the outset.
The request was granted, and we released the data publicly for the first time. Following our release, the state began reporting the data themselves, as was required from the outset.
October 23, 2025 at 1:16 PM
In 2023 we submitted a request to the PA Insurance Department for health insurer denial data from the state.
The request was granted, and we released the data publicly for the first time. Following our release, the state began reporting the data themselves, as was required from the outset.
The request was granted, and we released the data publicly for the first time. Following our release, the state began reporting the data themselves, as was required from the outset.
Health insurers should not be involved in judging disputes over the accuracy and medical merit of their own decisions.
They've long been granted the trust to do this, and repeatedly demonstrate they cannot fairly assess appeals. This is not opinion; it's supported by data.
They've long been granted the trust to do this, and repeatedly demonstrate they cannot fairly assess appeals. This is not opinion; it's supported by data.
October 22, 2025 at 8:02 PM
Health insurers should not be involved in judging disputes over the accuracy and medical merit of their own decisions.
They've long been granted the trust to do this, and repeatedly demonstrate they cannot fairly assess appeals. This is not opinion; it's supported by data.
They've long been granted the trust to do this, and repeatedly demonstrate they cannot fairly assess appeals. This is not opinion; it's supported by data.