The Acme Health Plan Appeals — Denial Ledger & Record
Member M. Rivera (fictional) · Acme Health Plan ID 00-DEMO · Prepared March 2026 (fictional)
In brief
Between September 2025 and February 2026, Acme Health Plan issued three adverse determinations on care ordered by the member's treating physicians: a prior-authorization denial for imaging, a mid-course termination of inpatient rehabilitation, and a coding-level denial of physical therapy. The member requested the plan's complete claim file after each determination, matched the plan's own published criteria against what its reviewers cited, and appealed on time at every level. All three determinations were resolved in the member's favor: one on internal appeal, one on binding external review, one by corrected refiling.
Every reversal below was won with paper the member already had — assembled, dated,
delivered on time, and quoted verbatim.
The deadline board — the first artifact, always
| Determination | Path | Window | Due | Status |
|---|---|---|---|---|
| 2025-09-08 denial | Internal appeal | 180 days | 2026-03-07 | FILED 2025-10-06 — 152 days early |
| 2026-01-12 termination | Expedited internal appeal | plan: 14 days | 2026-01-26 | FILED 2026-01-14 — 12 days early |
| 2026-02-02 final denial | External review (IRO) | 4 months | 2026-06-02 | FILED 2026-02-16 — decision 2026-03-12: OVERTURNED |
Denial ledger — their words, their file's gaps, the outcome
| Date | Claim/Auth | What was denied — their stated reason & the claim-file gap | Outcome |
|---|---|---|---|
| 2025-09-08 | PA-778812 | MRI, lumbar — prior auth DENIED — “not medically necessary; conservative therapy not exhausted” File gap: Criteria MSK-4.2 cited, not attached; reviewer credential not stated | OVERTURNED on internal appeal, 2025-11-03 |
| 2026-01-12 | CL-291044 | Inpatient rehab, days 15–28 post-op TERMINATED — “no longer meets criteria for continued stay” File gap: Letter identical wording 3 days running; treating physician not contacted | Internal appeal UPHELD 2026-02-02; external review OVERTURNED 2026-03-12 |
| 2026-02-04 | CL-293571 | Physical therapy ×12 DENIED — “duplicative of home exercise program” File gap: EOB code (J-12) differs from letter reason | Refiled by provider with corrected coding — PAID 2026-02-25 |
The record — 11 key documents (sample)
The claim-file request
The request that changed each case. After every adverse determination, the member
requested — free of charge, as the appeal rights provide — the complete claim record, the internal criteria
relied upon, the identity and specialty of each reviewer, and any expert opinions obtained. The gaps between
that file and the plan's own published criteria became the numbered points of each appeal.
The request letter (placeholder PDF).