Insurer denial rates, appeal outcomes by treatment and condition, and appeal rights lookups.
Maintain this server? Claim it
Call this server's tools from your browser. Nothing to install.
Requests go through mcptry because browsers can't call most MCP servers directly. Header values are sent to the server for that request only and are never stored or logged.
Tool list from our last check. Connect live to refresh it.
Deterministically resolve the governing appeal route, missing facts, filing recipient, deadlines, current external-review status, and verified grounds. Distinguishes Original Medicare, Medicare Advantage medical benefits, Part D pharmacy benefits, employer funding/governance, ACA, Medicaid, FEHB, TRICARE, and unknown coverage; unsupported or ambiguous routes fail closed.
Plan type
Denial reason category. Use 'prescription-drug' for medication denials — formulary exclusion, step therapy, quantity limits, or drug prior authorization — which return the formulary-exception grounds and their short decision deadlines.
Two-letter state code, e.g. 'ca'
For a drug denial, whether the medical or pharmacy benefit applies
Insurer slug for insurer-specific stats
Required to resolve job-based coverage
Required to resolve job-based state versus federal governance
Deterministically resolve the governing appeal route, missing facts, filing recipient, deadlines, current external-review status, and verified grounds. Distinguishes Original Medicare, Medicare Advantage medical benefits, Part D pharmacy benefits, employer funding/governance, ACA, Medicaid, FEHB, TRICARE, and unknown coverage; unsupported or ambiguous routes fail closed.
| Argument | Type | Description |
|---|---|---|
| state | string | Two-letter state code, e.g. 'ca' |
| program* | string | Plan type |
| appeal_stage | string | |
| drug_channel | string | For a drug denial, whether the medical or pharmacy benefit applies |
| insurer_slug | string | Insurer slug for insurer-specific stats |
| denial_reason* | string | Denial reason category. Use 'prescription-drug' for medication denials — formulary exclusion, step therapy, quantity limits, or drug prior authorization — which return the formulary-exception grounds and their short decision deadlines. |
| employer_type | string | Required to resolve job-based coverage |
| current_status | string | |
| funding_status | string | Required to resolve job-based state versus federal governance |
| regulatory_marker | string | |
| regulatory_state_basis | string |
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"required": [
"program",
"denial_reason"
],
"properties": {
"state": {
"type": "string",
"maxLength": 2,
"minLength": 2,
"description": "Two-letter state code, e.g. 'ca'"
},
"program": {
"enum": [
"medicare-advantage",
"original-medicare",
"medicare-part-d",
"erisa-employer-plans",
"aca-marketplace",
"medicaid",
"fehb",
"tricare",
"other-unknown"
],
"type": "string",
"description": "Plan type"
},
"appeal_stage": {
"enum": [
"initial-denial",
"internal-appeal-filed",
"first-internal-denial",
"final-internal-denial",
"external-review-filed",
"unknown"
],
"type": "string"
},
"drug_channel": {
"enum": [
"not-a-drug",
"medical-benefit",
"pharmacy-benefit",
"unknown"
],
"type": "string",
"description": "For a drug denial, whether the medical or pharmacy benefit applies"
},
"insurer_slug": {
"type": "string",
"description": "Insurer slug for insurer-specific stats"
},
"denial_reason": {
"enum": [
"medical-necessity",
"experimental-investigational",
"prior-authorization",
"out-of-network",
"not-covered-benefit",
"coding-billing-error",
"prescription-drug"
],
"type": "string",
"description": "Denial reason category. Use 'prescription-drug' for medication denials — formulary exclusion, step therapy, quantity limits, or drug prior authorization — which return the formulary-exception grounds and their short decision deadlines."
},
"employer_type": {
"enum": [
"private",
"government",
"church",
"union",
"unknown"
],
"type": "string",
"description": "Required to resolve job-based coverage"
},
"current_status": {
"enum": [
"awaiting-service",
"receiving-service",
"service-ended",
"post-service-claim",
"unknown"
],
"type": "string"
},
"funding_status": {
"enum": [
"fully-insured",
"self-funded",
"unknown"
],
"type": "string",
"description": "Required to resolve job-based state versus federal governance"
},
"regulatory_marker": {
"enum": [
"state-regulated",
"federal-or-self-funded",
"unknown"
],
"type": "string"
},
"regulatory_state_basis": {
"enum": [
"denial-letter",
"insurance-card",
"plan-document",
"residence-only",
"unknown"
],
"type": "string"
}
},
"additionalProperties": false
}External-review outcomes for a medical condition: how often insurance denials involving this condition were overturned, plus the most-fought treatments for it.
| Argument | Type | Description |
|---|---|---|
| slug* | string | Condition slug, e.g. 'obesity', 'autism', 'hepatitis-c' |
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"required": [
"slug"
],
"properties": {
"slug": {
"type": "string",
"description": "Condition slug, e.g. 'obesity', 'autism', 'hepatitis-c'"
}
},
"additionalProperties": false
}Drug-specific denial patterns and appeal strategy for the medications plans fight hardest over: GLP-1s (Wegovy, Zepbound, Mounjaro, Ozempic, Saxenda) and IBD biologics (Humira, Skyrizi, Stelara, Entyvio, Remicade, Rinvoq). Returns FDA-approved indications stated conservatively, why plans deny that specific drug, what winning appeals argue, and the step-therapy exception framing — plus the published external-review record for the drug when the corpus has it. Accepts a brand or generic name.
| Argument | Type | Description |
|---|---|---|
| drug* | string | Brand or generic drug name, e.g. 'Zepbound', 'ustekinumab' |
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"required": [
"drug"
],
"properties": {
"drug": {
"type": "string",
"maxLength": 80,
"minLength": 2,
"description": "Brand or generic drug name, e.g. 'Zepbound', 'ustekinumab'"
}
},
"additionalProperties": false
}Get an insurer's verified CY2025 prior-authorization metrics (denial rate, appeal overturn rate, decision times) from its own CMS-0057-F disclosure, plus contract/plan-level rows where collected. Includes source URLs and scope notes.
| Argument | Type | Description |
|---|---|---|
| slug* | string | Insurer slug from list_insurers, e.g. 'unitedhealthcare' |
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"required": [
"slug"
],
"properties": {
"slug": {
"type": "string",
"description": "Insurer slug from list_insurers, e.g. 'unitedhealthcare'"
}
},
"additionalProperties": false
}How a state's external review process works: filing deadline, regulator contact, and key facts. Verified detail currently covers 10 states (CA, TX, FL, NY, PA, IL, OH, GA, NC, MI); other states return the covered list.
| Argument | Type | Description |
|---|---|---|
| state* | string | Two-letter state code, e.g. 'ca', 'ny', 'fl' |
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"required": [
"state"
],
"properties": {
"state": {
"type": "string",
"maxLength": 2,
"minLength": 2,
"description": "Two-letter state code, e.g. 'ca', 'ny', 'fl'"
}
},
"additionalProperties": false
}External-review outcomes for a treatment: how often insurer denials of this treatment/drug/procedure were overturned by independent reviewers (42,749 published CA IMR decisions, 2001–2026). Accepts a category slug (e.g. 'pharmacy') or specific treatment slug (e.g. 'zepbound', 'speech-therapy').
| Argument | Type | Description |
|---|---|---|
| slug* | string | Treatment slug, e.g. 'zepbound', 'pharmacy', 'speech-therapy'. Use search_outcomes to find slugs. |
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"required": [
"slug"
],
"properties": {
"slug": {
"type": "string",
"description": "Treatment slug, e.g. 'zepbound', 'pharmacy', 'speech-therapy'. Use search_outcomes to find slugs."
}
},
"additionalProperties": false
}List tracked U.S. health insurers with whether verified CMS-0057-F prior-authorization metrics are available for each.
No arguments.
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"properties": {}
}Insurer prior-authorization denial rates (CY2025), ranked only within compatible reporting cohorts. Each row includes its cohort, rank within that cohort, exact source scope, calculation method, and source link. Never compare ranks across cohorts.
No arguments.
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"properties": {}
}Search treatments (categories + specific drugs/procedures) and conditions by name. Returns slugs for get_treatment_outcomes / get_condition_outcomes plus headline overturn rates.
| Argument | Type | Description |
|---|---|---|
| limit | integer | Max results per type (default 10) |
| query* | string | Search text, e.g. 'wegovy', 'back pain', 'imaging' |
{
"type": "object",
"$schema": "http://json-schema.org/draft-07/schema#",
"required": [
"query"
],
"properties": {
"limit": {
"type": "integer",
"maximum": 50,
"minimum": 1,
"description": "Max results per type (default 10)"
},
"query": {
"type": "string",
"minLength": 2,
"description": "Search text, e.g. 'wegovy', 'back pain', 'imaging'"
}
},
"additionalProperties": false
}