The AI Appeal That Won Lisa the Home Health Care She Deserved
Lisa K., a 71-year-old retired librarian, was dealing with a severe flare-up of Lupus and advanced Rheumatoid Arthritis (RA), which significantly impaired her mobility. Following a brief hospitalization, her rheumatologist ordered a few weeks of skilled home health care to help her manage complex medication injections and ensure safety while regaining strength. The projected cost for the necessary 6 weeks of skilled care was $11,500.
The insurer denied the claim, arguing the service was "custodial care" meaning they only covered "acute care" needs, not ongoing maintenance. Lisa was told to hire a non-medical aide.
Lisa's adult daughter used the Counterforce Health solution to manage the appeal process.
How Counterforce Health Stepped In:
- Denial Reclassification: Counterforce's system analyzed the denial language and automatically focused the appeal on the difference between custodial (daily assistance) and skilled (medical necessity).
- Evidence of Risk: The AI generated arguments based on Lisa's current complex medication regimen and the high risk of falling and re-hospitalization. The appeal included recent physician notes defining her current condition as acute functional impairment.
- The Result: The appeal successfully argued that limiting therapy now would lead to significantly higher costs and poorer outcomes later. The insurer approved the $11,500 in skilled care services under the "Medically Necessary Exception" clause.
Lisa received the skilled care she needed to manage her condition and safely transition back to full independence. "The insurance company just saw a number," her daughter explained. "Counterforce made them see the medical necessity and the risk of denying it, protecting both my mom's health and our savings."