Denial Reason Atlas
Denial rates by CPT, payer, and state.
With what happens when you appeal.
For any CPT code and commercial payer, surface the actual denial rate, the modal reason code, and the overturn rate on first-level appeal. The data exists — in state-mandated disclosures, TiC files, and the No Surprises Act IDR portal. Nobody has cross-referenced them. Until now.
Institutional license. Sold per engagement.
What the Atlas surfaces
For any CPT code × payer × state combination, the Atlas returns: denial rate, modal denial reason code (CARC), and overturn rate on first-level appeal. It is built by cross-referencing four primary sources that no one has joined at scale.
| CPT Code | Payer | State | Denial Rate | Modal CARC | Overturn Rate | Sample |
|---|---|---|---|---|---|---|
| 27447 (TKA) | Aetna | California | 18.4% | 197 — Prior auth required | 63% | 412 claims |
| 27447 (TKA) | UnitedHealthcare | California | 4.1% | 50 — Non-covered service | 31% | 1,204 claims |
| 99215 (Office visit) | Anthem | New York | 6.8% | 4 — Service inconsistent with diagnosis | 44% | 8,741 claims |
| 43239 (Upper endoscopy) | Cigna | Texas | 11.2% | 197 — Prior auth required | 78% | 673 claims |
| 93306 (Echocardiogram) | Humana | Florida | 9.7% | 96 — Non-covered charge | 52% | 2,311 claims |
| 70553 (MRI Brain w/ contrast) | BlueCross NC | North Carolina | 22.9% | 197 — Prior auth required | 71% | 891 claims |
Sample data from states with mandatory denial-rate disclosure. Confidence bands available per cell. Coverage is uneven by state — the methodology page lists which states have full, partial, or no coverage.
Why this data doesn't exist anywhere else
Payers don't publish denial rates by CPT code. Hospitals collect denial reason codes in 835 transactions but don't share them publicly. The signal becomes visible only by cross-referencing four sources:
State denial-rate disclosures
California, New York, Colorado, Washington, and a growing list require payers to disclose aggregate denial rates. Different formats, different granularity — Branmoor normalizes them.
CMS Transparency in Coverage
Allowed-amount files contain out-of-network payment records that imply denial patterns. The inference requires statistical methods; the source is public.
No Surprises Act IDR data
The federal independent dispute resolution portal publishes outcome data — which payer, which code, which result. Every IDR outcome is a de facto denial with a decision on the merits.
State insurance complaint data
State insurance departments publish consumer appeal data, often with outcome. Methodology varies by state; coverage and confidence are disclosed per cell.
Who buys it
Revenue Cycle Directors
Know which denials are worth working before you assign the staff. A 71% overturn rate on first-level appeal is a different prioritization than 22%. Stop working denials by payer; work them by payer × code × overturn probability.
RCM Service Companies
R1, Conifer, Ensemble, Optum360 — the Atlas is a productivity multiplier for the denial management teams you staff. Appeal brief templates built on the arguments that actually work against each payer.
Healthcare M&A Diligence
Underwriting an RCM-intensive target? The denial rate by payer tells you how much of the revenue cycle is structurally at risk. One metric that doesn't exist in any sell-side model.
Primary data sources
| Source | What it provides | Coverage |
|---|---|---|
| State-mandated denial-rate disclosures | Aggregate denial rates by payer where required | CA, NY, CO, WA + growing list |
| CMS Transparency in Coverage | Out-of-network allowed-amount records | All commercial payers nationally |
| No Surprises Act IDR Public Use Files | IDR outcomes by payer and service | Federal — all states |
| State insurance department complaint data | Consumer-filed appeal data with outcomes | Varies by state |
| CMS Marketplace appeals data | ACA plan appeal outcomes by issuer | Federal — ACA plans |
Inquire about access
Denial Reason Atlas is sold under named institutional license, scoped per engagement. Reach out with your organization, role, and the CPT codes and payers you care about most.