AI Tools Help Patients Fight Insurance Denials

Published Date : 19/07/2025 

Stephanie Nixdorf, a mother of four, used artificial intelligence to fight against health insurance denials and successfully received coverage for her arthritis treatment. 

Stephanie Nixdorf was enjoying a family trip to Disney World in December 2021 when she received a life-changing call. Her doctor informed her that a mysterious bump on her elbow was melanoma, and further tests revealed it was Stage 4, with spots on her lung and two tumors in her brain. Nixdorf, 51, a mother of four living in Davidson, North Carolina, began treatments immediately. By January 2024, her cancer was abating, but her health insurance, provided by Premera Blue Cross, started denying her requests for a drug to treat the arthritis induced by her immunotherapy treatments.

“I used to run, play tennis, be active,” Nixdorf told NBC News. “Now I can’t even open a yogurt or grip a steering wheel in the morning.”

Premera Blue Cross, a not-for-profit health plan in the Pacific Northwest serving 2.5 million people, denied Nixdorf’s requests for infliximab, an inflammatory arthritis drug, for nine months in 2024. Desperate to help his wife, Jason Nixdorf had a chance encounter with Zach Veigulis, a former chief data scientist at the Department of Veterans Affairs who was co-founding a company to help patients battle insurance denials. This company, Claimable Inc., developed an AI platform that generates customized appeal letters containing comprehensive assessments of clinical research and past appeals history.

When Nixdorf reached out, Claimable’s site was not yet live, but its CEO and co-founder, Dr. Warris Bokhari, offered to help write an appeal letter for Stephanie. In mid-September 2024, she sent a 23-page appeal letter to Premera’s CEO and chief legal counsel, arguing that one of its own policies should cover infliximab. The letter also went to North Carolina’s governor and attorney general, officials at the Department of Health and Human Services, the Consumer Financial Protection Bureau, and the Wage and Hour Division of the Department of Labor.

Two days later, Premera approved the drug. “I want to apologize that you have been waiting to receive treatment for nine months,” the approval letter stated.

Nixdorf is part of a growing cohort of patients using artificial intelligence to challenge health insurance denials. Several companies offer software programs that allow patients to create comprehensive appeal letters quickly, leveraging AI to gather evidence of drug efficacy and past appeals success in a fraction of the time it would take a human.

Courtney Wallace, a Premera spokeswoman, provided a statement on the Nixdorf case. “There was no intent to deny care,” she said. “Rather, Premera made a processing error involving a misapplication of policy and assignment to an incorrect physician specialist.” Premera acknowledged they “fell short” in this case.

Research shows that the arthritis Nixdorf was experiencing, if untreated, can cause irreversible joint damage and significant disability. Jason Nixdorf expressed relief but also anger over the ordeal. “Not only has the delay caused Stephanie permanent damage,” he said, “it will be a lifelong thing for her to deal with this arthritis. If we had gotten the OK in January, it could have been knocked out and done then.”

As many patients and their doctors know, trying to gain insurance coverage for a drug or treatment can be a full-time and exasperating task. Comprehensive data on insurance company denials is unavailable, but a January 2025 study by KFF, a health policy research organization, found that insurers participating in marketplace plans under the Affordable Care Act denied 19% of in-network claims in 2023. Fewer than 1% of consumers appealed the denials, and when they did, over half the denials — 56% — were upheld.

In addition to the impact on patients’ health, insurance denials carry a financial cost. A 2023 KFF survey found that 39% of consumers having trouble paying medical bills cited denied claims as a contributing factor.

Amid the fight over Premera’s denials, the Nixdorfs and their doctors repeatedly tried to set up a case review by calling a toll-free number that was never answered, leaving messages that were not returned, faxing documents, and completing letters of medical necessity. Premera’s first denial came in February when the insurer said infliximab was “not medically necessary.” A second denial in June characterized the drug as “investigational or experimental,” despite it being recommended by the National Comprehensive Cancer Network Drugs and Biologics Compendium. The third denial in July stated infliximab was not FDA-approved.

“They set the system up so people give up,” Jason said. After the third denial, Jason requested all the records relating to Premera’s decision. He and his wife became troubled when they received the materials, learning, for example, that the doctor used by Premera in a peer-to-peer review had no expertise in cancer or inflammatory arthritis.

They also discovered that the company contracted by Premera to do an independent review of their case — AllMed Healthcare Management — was led by Jeff Card, a former Premera executive. Having his wife’s case reviewed by a company overseen by a former Premera executive presented a conflict of interest, Nixdorf told NBC News.

Premera’s spokeswoman declined to respond to this criticism, stating that AllMed is accredited by the National Committee for Quality Assurance and the Utilization Review Accreditation Commission. Premera’s partnership with AllMed is “subject to rigorous oversight, including quarterly reviews and audits” by the insurer.

Veigulis of Claimable said the company’s three co-founders wanted to understand why people who have access to health care don’t receive it. Building their AI model, they began with rheumatology and migraine and now cover over 50 life-changing treatments. Veigulis said roughly 1,000 denials have been overturned by patients using the Claimable model.

“We see so many people who have met the eligibility criteria who pay their premiums on time that still can’t access their health care,” he said. “It is wild.”

Tabitha Lee, a former paramedic working in rheumatology at Wilmington Health in North Carolina, has handled prior authorization and insurance denials for the roughly 100 patients who come in each day since January. Denials have ramped up recently, she said.

“You have rights,” Lee emphasized. “Don’t give up.” 

Frequently Asked Questions (FAQS): 

Q: What is Claimable Inc.?

A: Claimable Inc. is a company that uses artificial intelligence to help patients create comprehensive appeal letters to challenge health insurance denials. It provides a platform that generates customized letters containing clinical research and past appeals history.

Q: How effective are AI-generated appeal letters?

A: AI-generated appeal letters have been effective in overturning insurance denials. According to Claimable Inc., roughly 1,000 denials have been overturned by patients using their AI model.

Q: What are common reasons for insurance denials?

A: Common reasons for insurance denials include claims being deemed not medically necessary, treatments being labeled as investigational or experimental, and drugs not being FDA-approved.

Q: How can patients appeal insurance denials?

A: Patients can appeal insurance denials by submitting comprehensive appeal letters that include clinical research, past appeals history, and any relevant medical documentation. They can also seek legal assistance and contact state health departments or consumer protection agencies.

Q: What is Premera Blue Cross?

A: Premera Blue Cross is a not-for-profit health plan in the Pacific Northwest, serving 2.5 million people. It is a leading health plan and a licensee of the Blue Cross Blue Shield Association. 

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