One cite from the reversal
Medicare appeals run a five-level ladder (redetermination, reconsideration, ALJ, MAC, federal court), each with its own evidentiary rules, deadlines and reversal patterns. Owl reads the medical record, the LCD/NCD, the plan and the appeal, walks the ladder, and says: overturn, escalate, or pay.
L1 → L3
Highest reversal probability
58% / L3 ALJ
Average ALJ reversal rate
$0
Cost of conceding correctly at L1
Three AI agents on a Medicare appeal. Reading. Cross-referencing. Answering.
One appeal: a denied skilled-nursing claim where Jimmo changes everything.
Anonymized composite: Medicare Advantage member, age 78, post-stroke, denied SNF days 21-100 for "lack of progress."
External data only. None of this lives in your CMS. Owl gathered it from public records, professional networks, registries and the open web, then resolved it to this claimant.
The Jimmo v. Sebelius settlement (2013, reaffirmed 2017) prohibits Medicare from requiring "improvement" as a condition of skilled SNF or home-health coverage. Skilled maintenance therapy is covered when the skill of a therapist is required to maintain function or prevent decline. Plan denial cites the prohibited standard verbatim.
In Owl’s tracking of this MA contract, four prior denials on the identical Jimmo-improvement-standard issue have been overturned at L1 redetermination in the last 18 months. Reversal at L1 is consistent with this plan’s own appeals history.
CMS 2025 Workplan and OIG audit priorities include MA-plan compliance with Jimmo. Persistent denial under the improvement standard is an audit-flag risk for the contract; reversing at L1 reduces audit and CMP exposure.
PT/OT notes document skilled maintenance: gait training with cuing, transfer training, balance interventions requiring therapist judgment. Falls below "improvement" but well above "unskilled" maintenance. Meets 42 CFR 409.32 skill-required threshold.
Overturn at L1. Three reasons. (1) The denial cites the Jimmo-prohibited improvement standard verbatim; at ALJ, this is a near-certain reversal (Owl tracks 91% reversal rate on this exact pattern). (2) This MA contract has overturned four prior identical denials at L1 in the last 18 months; the precedent is internal. (3) CMS 2025 Workplan flags this as audit-priority; holding to L3 raises audit and CMP exposure. Recommend full overturn at L1 with cited reasoning, plus a remediation note for the contract’s denial-template language.
Draft prepared. Decision: favorable to appellant. Rationale (member-readable): "We reviewed your appeal of the denial of skilled nursing facility days 21-100. The original decision said you were not getting better. Under the Medicare rules established by the Jimmo Settlement (2013), Medicare must cover skilled care that is needed to maintain your function or prevent decline, not only care that produces improvement. Your therapy records show that the skill of a therapist was required for your gait, transfer, and balance training. We are reversing the denial. Days 21-100 are covered." Provider-side and CMS-format versions also drafted.
What the world says about your Medicare claimants, none of which lives in your CMS.
Internal claim data is half the picture: it tells you what the claimant told you. OwlSignal continuously gathers external data (public records, professional and corporate registries, court dockets, social and open web) and matches it back to the claimant. These are the families that move the needle on Medicare.
Every Local Coverage Determination, National Coverage Determination, and CMS Internet-Only Manual chapter, walked element-by-element on every appeal.
Owl’s cross-MA-plan + Original-Medicare appeal-outcome graph (4.8M tracked appeals): reversal rate by issue, by stage, by plan contract, by ALJ.
CMS annual Workplan, OIG Workplan, RAC focus areas, MA audit-priority topics, and CMP precedent on plan-side denial behavior.
Departmental Appeals Board decisions, Medicare Appeals Council remand patterns, and federal-court Medicare precedent (Jimmo, Wilkes, Ortiz, etc.), read once, applied on every appeal.
Every Medicare Advantage plan’s Evidence of Coverage, formulary, network rules, prior-auth list, and the per-contract reversal-rate Owl tracks for examiner targeting.
CMS skilled-care criteria, therapy documentation standards, MOON/IMM notice rules, and the documentation patterns that distinguish skilled from unskilled care defensibly.
Numbers from MA plans and appeal vendors running Owl on Medicare appeals in production.
Built for the regulatory shape of Medicare.
Lives where your Medicare files live.
MA core admin
HealthEdge HealthRules, Trizetto Facets, ikaSystems
Appeals platforms
MCG, InterQual, Cohere, in-house
Records intake
MRO, Verisma, Datavant, ChartRequest
CMS systems
HPMS, CMS appeals portal (per plan policy)
Document intake
Box, OnBase, ImageRight
Identity & SSO
Okta, Azure AD, PingFederate, SAML, SCIM
Bring us a quarter of Medicare appeals. We’ll show you the L1 reversals on day one.
Two-week pilot. Your appeals stream, your tenant, your plan EOC. We measure cycle time, L1 overturn rate, ALJ surprise-reversal rate and audit-readiness against your own ground truth.