ArticleHealth affairs (Project Hope)2022
Coverage Denials: Government And Private Insurer Policies For Medical Necessity In Medicare.
Article in Health affairs (Project Hope), 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 10 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
10 citing papers in PubMed.
- Second-Level Appeals of Denied Anticancer Medication Claims in Medicare Part D.JAMA network open · 2026Article
- Shifting barriers to health care access: from affordability to coverage issues.BMC health services research · 2026Article
- Integrating Prior Authorization Into Clinical Workflows for Care Access and Practitioner Experience.JAMA network open · 2025Article
- Prior Authorization, Quantity Limits, and Step Therapy for Patient-Administered Antiemetics.JAMA network open · 2025Article
- Evaluation of Low-Value Services Across Major Medicare Advantage Insurers and Traditional Medicare.JAMA network open · 2024Article
- Prior Authorization and Association With Delayed or Discontinued Prescription Fills.Journal of clinical oncology : official journal of the American Society of Clinical Oncology · 2024Article
- Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage.BMJ (Clinical research ed.) · 2024Article
- A Policy Approach to Reducing Low-Value Device-Based Procedure Use.The Milbank quarterly · 2022Article
- Comparison of Low-Value Services Among Medicare Advantage and Traditional Medicare Beneficiaries.JAMA health forum · 2022Article
- Medicare Advantage Enrollment and Total Medicare Program Spending.Inquiry : a journal of medical care organization, provision and financingArticle
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
7 authors.
Funding
Abstract
Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their key features, using Medicare Advantage claims for a large insurer from the period 2014-19. In this setting, claims could be denied because of traditional Medicare's coverage rules or additional Medicare Advantage private insurer rules. We observed $416 million in denied spending, with 0.81 denials and $60 of denied spending per beneficiary annually. We found that 1.40 percent of services were denied and 0.68 percent of total spending was denied, with rates rising over time. Traditional Medicare's coverage rules accounted for 85 percent of denied services and 64 percent of denied spending; the remaining denials were due to additional Medicare Advantage insurer rules. Denial rates varied greatly across service type and provider type, with the most denials being for laboratory services and hospital outpatient providers. Traditional Medicare and Medicare Advantage insurer coverage policies each addressed different sources of medical spending; together they contributed to the denial of a modest but nontrivial portion of payments.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.