Part II: How non-clinicians and 1.2 second algorithms overrule attending physicians on medical necessity, why the appeal math makes denials profitable, and which federal rules could change it

Medicare Advantage plans process 50 million prior auth decisions a year. When patients appeal, payers overturn their own denials over 80% of the time. The initial denial layer is calibrated to something other than clinical accuracy.

Medical necessity is not a medical concept. It is a contract term interpreted by the payer. A physician can be 100% right t…