com.coverage-rights/coverage-rights

Tools

• get_appeal_rights

  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.

  shallow
• get_condition_outcomes

  External-review outcomes for a medical condition: how often insurance denials involving this condition were overturned, plus the most-fought treatments for it.

  shallow
• get_drug_playbook

  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.

  shallow
• get_insurer_metrics

  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.

  shallow
• get_state_external_review

  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.

  shallow
• get_treatment_outcomes

  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').

  shallow
• list_insurers

  List tracked U.S. health insurers with whether verified CMS-0057-F prior-authorization metrics are available for each.

  shallow
• rank_denial_rates

  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.

  shallow
• search_outcomes

  Search treatments (categories + specific drugs/procedures) and conditions by name. Returns slugs for get_treatment_outcomes / get_condition_outcomes plus headline overturn rates.

  shallow

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