Rejected Services Medical Review
2026-04-28 to 2026-09-28 • Generated 29 Sep 2026
Important interpretation75.7% of records use coverage, history, duplication, documentation, or provider-action reasons. Their correctness cannot be decided medically from diagnosis and service alone; benefit rules or supporting records are required.
Rejected services reviewed
600
400 approvals • 213 members
Likely justified medically
111
Diagnosis/service rationale supported
Likely not justified
13
Priority for clinical reconsideration
Needs more evidence
476
Clinical context, policy, or history missing
Decision composition
All 600 rejected services
600services
Decision mix by client
Stack length represents services; click a segment to review that client
Top rejection reasons
Click a bar to open matching case-level records
Rejected services over time
Monthly count across all three clients
Decision distribution
Executive brief
- 146 cases had a reason that could be clinically reviewed from the available fields; 454 were primarily contractual or evidence-dependent.
- Among clinically conclusive reviews, 10.5% were flagged as likely not justified and should be prioritized for medical-director review.
- The analysis is intentionally conservative: ambiguous cases are marked Indeterminate, not overturned.
- Coverage decisions are not labelled medically right or wrong without policy wording, even when the requested service may clinically fit the diagnosis.
Recommended audit order
1) Likely not justified with confidence ≥80%; 2) Indeterminate high-cost tests/procedures; 3) coverage/history cases after policy and claims evidence are joined.
1) Likely not justified with confidence ≥80%; 2) Indeterminate high-cost tests/procedures; 3) coverage/history cases after policy and claims evidence are joined.
Top review priorities
| Client | Approval | Member | Service | Recorded diagnosis | Finding | Confidence |
|---|
View by client
Client comparison
| Client | Services | Approvals | Members | Likely justified | Likely not justified | Indeterminate | Not assessable | Avg. confidence |
|---|
View by member
| Member | ID | Client | Services | Approvals | Likely not justified | Indeterminate | Not assessable | Action |
|---|
View by rejection reason
| Rejection reason | Services | Members | Likely justified | Likely not justified | Indeterminate | Not assessable | Avg. confidence | Action |
|---|
Case-level review
| # | Date | Client | Approval / Act | Member | Service | Rejection reason | Diagnosis | Medical-review finding | Review description | Confidence |
|---|
Methodology and limitations
What was reviewed
Each row was assessed using only the supplied client, approval date, service, rejection reason, member, and diagnosis fields. Diagnosis codes and names were treated as recorded, without assuming unlisted symptoms or comorbidities.
Decision categories
- Likely justified: the stated clinical mismatch or lack-of-need rationale is consistent with the recorded diagnosis and common clinical practice.
- Likely not justified: the recorded diagnosis provides a direct or plausible indication, so the stated medical reason appears weak or incorrect.
- Indeterminate: a decision depends on missing symptoms, examination, prior results, interval, active ingredient, or treatment context.
- Not medically assessable: the reason is contractual/procedural (coverage, prior dispensing, duplication, missing report, or provider action) and requires evidence outside this file.
Confidence
Confidence measures confidence in this review classification—not certainty that the original claim should be paid. A high confidence on “Not medically assessable” means high confidence that the supplied fields are insufficient to validate that reason.
Clinical framework
The review used diagnosis–service concordance, usual indication, documented red flags, and whether common guidance supports routine use. Examples include ACR imaging appropriateness, ADA diabetes screening principles, and NICE guidance for IBS and osteoarthritis.
Material limitations
- No benefit schedule, exclusions, limits, prior authorization rules, claims history, formulary, active-ingredient master, quantities, or accepted alternatives were supplied.
- No clinical notes, age, sex, vital signs, examination, laboratory values, imaging findings, medication list, dose, or treatment duration were supplied.
- This is a screening-level audit for prioritization. Final determinations require the complete record and review by an appropriately licensed clinician/medical director.