AI Appeal Overturns Insurance Denial for Delaware County Woman's ADHD Medication

AI-Built Appeal Overturns ADHD Med Denial-What This Means for Insurers

A Delaware County member, Joani Reisen, lost coverage for Concerta, a medication she had used for years to manage ADHD. Her plan flagged the drug as "experimental" and pushed a generic alternative that she said made her fall asleep without warning.

Reisen used Counterforce Health, a free AI platform that generates evidence-rich appeal letters. In minutes, it produced an 11-page appeal arguing Concerta was not experimental for her diagnosis. Independence Blue Cross later said coverage was dropped due to a diagnosis oversight and reinstated the benefit once corrected.

What Happened

* Medication: Concerta (methylphenidate ER) for ADHD, used successfully for more than a decade.
* Plan action: Labeled the drug "experimental" and required a generic switch.
* Member report: Generic option caused adverse effects and did not control symptoms.
* Appeal: AI-generated letter with clinical citations; coverage restored after the diagnosis issue was fixed.

Why This Matters for Insurance Teams

• AI is speeding up member appeals. Expect more long, citation-heavy letters that look like legal briefs.
• Misclassification risk is real. A simple diagnosis code oversight triggered a denial and a costly, time-consuming appeal.
• Formulary exceptions hinge on outcomes. Documented failure or intolerance to generics can justify brand coverage.
• Operational throughput will be tested. Intake, triage, and clinical review must handle higher volume without missing key facts.

Operational Playbook: Reduce Avoidable Overturns

• Tighten policy language: Define "experimental/investigational" with clear, public criteria and align with medical policy numbering and citations.
• Codify exception criteria: For ADHD stimulants, specify required trials, duration, adverse effects, and documented outcomes for generic failure.
• Structured submissions: Require a simple template: diagnosis codes, prior therapies tried/failed, dates, adverse events, prescriber attestation, and supporting records.
• AI-era triage: Use NLP to extract claims, diagnoses, and citations from member letters. Route high-likelihood overturns for expedited review.
• Source verification: If the appeal cites journals or guidelines, spot-check key references. Ask for medical records to corroborate claims.
• Preventive audits: Track top denial reasons that later overturn (e.g., coding oversights, step-therapy edge cases). Fix upstream rules and job aids.
• Member/provider comms: Send plain-language letters that list exact missing items and how to fix them in one step.
• Turnaround time discipline: Monitor and publish internal SLAs for urgent med appeals to reduce escalations and complaints.

Clinical Context: ADHD ER Stimulants

• Extended-release methylphenidate products use different delivery systems. Patient response can vary across brands and generics.
• Exception requests are stronger with documented lack of efficacy or adverse effects on alternatives, plus the prescriber's clinical rationale.
• Background on generic equivalence: see FDA guidance on therapeutic equivalence for context on AB-rated products (FDA overview).

Compliance Guardrails

• Verify your appeals workflow meets federal timelines and content standards for group health plans (DOL claims and appeals rules).
• Document the rationale for any "experimental" determination and include citations members can access.
• Log overturn root causes and feed them back into utilization management policies and editing rules.

Checklist: Handling AI-Generated Appeals

• Identify the claim: diagnosis, med, policy cited, reason for denial.
• Confirm coding: ensure diagnosis aligns with the indication and policy.
• Evidence triage: extract cited studies/guidelines; verify 1-2 key sources.
• Clinical proof: require prescriber attestation and medical records for trials/side effects.
• Decision memo: write a clear, member-facing rationale with next steps if criteria aren't met.

Team Enablement

If your utilization management or appeals team is piloting AI, align on data privacy, source verification, and human-in-the-loop review. Track metrics such as overturn rate, time to decision, and member effort to prove value and detect drift.

Want practical training to upskill your team on AI for review workflows and documentation? Explore curated courses for job roles here: AI courses by job role.