Your Claim Was Denied in Seconds. Did Anyone Actually Read It?

In my years working in specialty pharmacy, I learned to recognize a particular kind of denial. Not the careful, reasoned kind, where someone has read the chart and disagrees. The other kind — the one that comes back so fast you know no one could have opened the file.

Here is a story I still hear from the field. A patient on intravenous immunoglobulin, or IVIG — a treatment people with immune deficiencies and certain neurological conditions depend on — meets every clinical criterion the plan requires. The request is submitted with the full chart. The denial comes back in about five minutes. At one specialty pharmacy, the people doing this work say a majority of their patients — on the order of two out of three — are denied on the first try, even when the paperwork is airtight. And in one case, a denial letter referred to SCIG — subcutaneous immunoglobulin, a standard form of the same therapy — as a "Squirrel Cage Induction Generator." That is an electrical engineering term. It has nothing to do with medicine. It is the kind of error a careful human reviewer does not make, and an automated system pulling the wrong expansion of an abbreviation does.

I cannot put a verified national number on that pharmacy's experience, and I will not pretend to. But the pattern it describes — denials issued faster than any person could read a chart — is not a rumor. It is documented.

What the records show

In 2023, ProPublica reported on an internal system used by the insurer Cigna, called PxDx, that let the company deny large batches of claims as "not medically necessary" without a medical professional opening the file. Over a two-month period, company doctors denied more than 300,000 requests this way, spending an average of about 1.2 seconds on each case. One doctor, the reporting found, denied roughly 60,000 claims in a single month. A class-action lawsuit and a congressional inquiry followed (ProPublica; Associated Press).

A second case is moving through federal court now. The estate of a Medicare Advantage patient is leading a class action against UnitedHealth Group, alleging the insurer used an AI tool called nH Predict to wrongfully cut off post-acute care — the rehabilitation and nursing care people need after a hospital stay — overriding what treating clinicians had determined. In early 2026, a federal magistrate judge ordered UnitedHealth to turn over internal documents about how the algorithm actually worked. The case has been allowed to proceed (Healthcare Finance News; Becker's).

The insurers dispute the allegations, and the lawsuits are not yet resolved. But the underlying mechanism is no longer in question: claims can be, and have been, denied at a speed and scale that no human review could match.

Why the missing human matters

An algorithm can be a useful tool. The danger is not the software. The danger is the missing human — the meaningful review that is supposed to stand between a computer's recommendation and a real person's care. When that review is reduced to a rubber stamp, or skipped entirely, two things happen. Mistakes that a clinician would catch — like calling a routine immunoglobulin therapy a piece of industrial machinery — sail straight through. And patients who meet every criterion get a "no" that was never really a decision at all.

This is the gap Ellen was built around. An automated denial is fast, but it is also brittle: it counts on you accepting it. The federal data is blunt on this point. According to the Kaiser Family Foundation's analysis of Medicare Advantage data, fewer than one in ten denied prior-authorization requests are ever appealed — and when patients do appeal, the majority of those denials are overturned. The system, in other words, is built on the expectation that you will walk away.

What you can do today

Do not treat a fast denial as a final one. A denial that arrives in minutes is often the weakest kind — and the most worth challenging.

Ask, in writing, for the specific clinical reason your claim was denied and the name and credentials of the reviewer who made the decision. You are entitled to a real answer.

Request the plan's coverage policy for your treatment. If you meet the listed criteria, your appeal can say so, point by point.

Appeal. Especially if you met every requirement and the "no" came back faster than anyone could have read your file.

Ellen can help you read your denial, find the policy behind it, and build the appeal — the human counterweight to an automated no. The machine is fast. It is not always right. And it is counting on you not to push back.

Ellen does not provide medical advice. For treatment decisions, talk to your doctor.

Sources: ProPublica; Associated Press; CBS News; Healthcare Finance News; Becker's Payer Issues; Kaiser Family Foundation; American Medical Association 2024 Prior Authorization Physician Survey.