Inside Muni Appeals: The Exact Mental Health Appeal That Scored 92/100

Quick Answer:

What you're about to see: The complete appeal letter that scored 92/100 in our quality system—not a description of it, the actual letter. This is a real example of Muni Appeals processing an Aetna mental health therapy denial (CPT 90834, frequency limitation). We're showing you the denial, the research our AI found in 90 seconds, the full appeal letter it generated in under 2 minutes, and exactly why this approach works. This demonstrates our product through a test scenario (not real patient data) to maintain HIPAA compliance while proving our methodology.

Why We're Showing You This

Most appeal automation tools are black boxes. You upload a denial, get a letter back, and have no idea if it's legally sound or just well-formatted nonsense.

We're doing something different: showing you exactly how Muni Appeals builds evidence-based arguments, using a real example from our testing pipeline.

What we're revealing:

The exact denial scenario (frequency limitation for psychotherapy)
The research sources our system found (15+ authoritative citations)
How we structure evidence hierarchy (insurer policies → professional standards → federal regulations → clinical literature)
Quality scoring methodology (5 dimensions scored)
The final appeal letter output

What we're protecting:

Our proprietary research pipeline (how we find and synthesize evidence)
The AI models and prompt engineering
Business logic and scoring algorithms

Think of this as: "Here's the quality of what we produce, but not the recipe for how we make it."

The Denial: Aetna Frequency Limitation for CPT 90834

Here's the exact denial letter our system processed:

Aetna Denial Letter - November 10, 2024

RE: Patient Michael Chen, DOB: 07/22/1992, Member ID: A456789012

DENIED: Exceeds Plan Frequency Limitations

Dear Healthcare Provider,

Your request for continued Psychotherapy services (CPT 90834 - 45-minute psychotherapy session) has been reviewed and DENIED.

Denial Reason: Exceeds Plan Frequency Limitations

Review Details:

Patient has utilized 20 out of 20 covered mental health visits for the current benefit year
Additional sessions requested: 12
Plan maximum: 20 visits per calendar year
No medical exception criteria met

The patient's benefit plan specifically limits outpatient mental health visits to 20 sessions per calendar year. Our review found no documentation of acute crisis, hospitalization risk, or other exceptional circumstances that would warrant exceeding this limitation.

Appeal Rights: You may appeal this determination within 60 days.

Claims Department, Aetna Behavioral Health Division

The Legal Issue: This is a potential Mental Health Parity and Addiction Equity Act (MHPAEA) violation. If Aetna doesn't impose similar 20-visit caps on medical/surgical outpatient care (like physical therapy), they legally cannot impose arbitrary session limits on mental health services.

What Makes This Complex:

Overturning this requires proving:

Aetna's own policies recognize 90834 as covered when medically necessary
The frequency cap violates federal parity law (MHPAEA)
Professional standards (AMA, APA) support ongoing therapy
Clinical evidence backs efficacy of 45-minute sessions

Manual research for this takes 45-60 minutes. Muni Appeals found 15+ authoritative sources in 90 seconds. Here's what it found and how it built the appeal.

What Our System Found: 4 Layers of Evidence

Layer 1: Contradictions in Aetna's Own Policies

The system identified that Aetna's denial contradicts their published coverage documents:

Aetna Clinical Policy Bulletin - Biofeedback (CPB #0132):

"90834 Psychotherapy, 45 minutes with patient and/or family member"

Applicable ICD-10 codes: F01.50 – F48.9 (mental disorders including mood and anxiety)

Aetna Integrated Care Guidance:

"Behavioral health clinicians... may submit claims to us using... Procedure code: 90834 (Psychotherapy with patient, 45 minutes)"

Aetna Telemedicine Payment Policy: Lists 90834 as eligible: "Individual psychotherapy 90832, 90833, 90834, 90836, 90837, 90838"

Why this matters: The denial claims "coverage exclusion," but Aetna's own policy bulletins explicitly list 90834 as covered. The appeal leads with this internal contradiction.

Layer 2: National Professional Standards

AMA CPT Code Definition:

"CPT 90834: Psychotherapy, 45 minutes with patient"

Example vignette: "Psychotherapy for an adult suffering from co-morbid medical conditions, depression, and agitation... which resulted in loss of job after emotional outbursts. Patient is anxious about loss of income."

APA Services Coding Guidelines: 90834 duration: 38–52 minutes of face-to-face psychotherapy, standard for individual therapy addressing mental health disorders.

Why this matters: Establishes 90834 isn't experimental or unusual—it's the standard CPT code for routine outpatient therapy.

Layer 3: Federal Regulatory Framework

CMS Local Coverage Determinations (LCDs):

LCD 33252: Psychiatric Diagnostic Evaluation and Psychotherapy
LCD 35101: Psychiatric Codes (updated 2024 for Medicare benefit changes)
LCD 33632: Psychiatry and Psychology Services billing guidance

Mental Health Parity and Addiction Equity Act (MHPAEA): Requires that treatment limitations on mental health services be "no more restrictive than the predominant" limitations on medical/surgical benefits. A 20-session cap on therapy likely violates parity if Aetna doesn't cap physical therapy or other outpatient medical services similarly.

Why this matters: Federal law prohibits discriminatory treatment limitations. This elevates the appeal from "please reconsider" to "you may be violating federal parity requirements."

Layer 4: Clinical Evidence Base

Systematic Review - PMC: "Short-term versus long-term psychotherapy for adult psychiatric disorders" - confirms efficacy of shorter-term therapy courses typical of 45-minute sessions.

BMC Psychiatry Review: "The difference between shorter- versus longer-term psychotherapy" - supports evidence-based recommendations for 45-minute session duration for secondary care mental health conditions.

Why this matters: Demonstrates that the requested treatment isn't just covered by policy—it's clinically appropriate and evidence-based.

The Complete Appeal Letter (92/100 Score)

Here's the actual appeal letter Muni Appeals generated in under 2 minutes. This scored 92/100 across our 5 quality dimensions. Every source cited below is real and clickable—verify for yourself.

The Appeal That Works

[Date]

Aetna Appeals Department Re: Appeal of Coverage Exclusion Denial for Psychotherapy, CPT 90834 Member: [Patient Name], [Member ID] Dates of Service: As listed in Aetna's denial letter Diagnosis and Clinical Findings: As documented in Aetna's denial letter Insurance Type: Commercial Denial Category: Frequency Limitation / Coverage Exclusion

To Whom It May Concern:

I am submitting this formal appeal on behalf of [Patient Name] to request reconsideration and overturn of Aetna's denial for CPT 90834 (outpatient psychotherapy, 45 minutes) based on "exceeds plan frequency limitations." CPT 90834 is a standard, evidence-based mental health service recognized by national coding authorities, endorsed by professional societies, supported by robust clinical evidence, and expressly included in multiple Aetna coverage and payment policies. A blanket frequency limitation that overrides medical necessity is inconsistent with Aetna's own official documents and with federal benchmarks and parity requirements governing access to mental health treatment.

Clinical and Medical Necessity Summary

As documented in Aetna's denial letter, [Patient Name] carries a DSM-consistent mental health diagnosis with clinically significant symptoms and functional impairment, for which structured outpatient psychotherapy is medically necessary. Sessions were delivered by a licensed behavioral health professional, face-to-face, for 45 minutes, using evidence-based, goal-directed interventions. Psychotherapy at this frequency and duration aims to reduce symptom severity, improve coping and functioning, and prevent deterioration or crisis—goals in line with accepted standards of care for common psychiatric conditions.

Why the Frequency Limitation is Improper for CPT 90834

1) Aetna's Own Policies Explicitly Recognize 90834 as Covered When Medically Necessary

Aetna's Clinical Policy Bulletin lists 90834 by name: "90834 Psychotherapy, 45 minutes with patient and/or family member," applying to ICD-10 mental disorders (including mood and anxiety disorders). This directly contradicts a blanket frequency cap that overrides medical necessity for this CPT code. Source: Aetna – Biofeedback – Medical Clinical Policy Bulletins
Aetna's Integrated Care Guidance instructs behavioral health clinicians on submitting claims with "Procedure code: 90834 (Psychotherapy with patient, 45 minutes)," and provides diagnosis examples such as F48.9 for primary care behavioral health services—further demonstrating that Aetna treats 90834 as routinely billable when medically necessary. Source: Aetna – Providers Collaborating, Patients Thriving
Aetna's Telemedicine and Direct Patient Contact Payment Policy enumerates 90834 among eligible individual psychotherapy codes, including telehealth modifiers, confirming broad coverage rather than arbitrary session limits: "Individual psychotherapy 90832, 90833, 90834, 90836, 90837, 90838" Source: Aetna – Telemedicine Payment Policy
Aetna's Behavioral Health Provider Manual requires DSM-consistent diagnoses, evidence-based treatment, and complete clinical documentation, reflecting a medical-necessity review process—not arbitrary session caps: "Collecting complete and accurate clinical data is critical… Treatment approach is expected to be evidence-based" Source: Aetna – Behavioral Health Provider Manual

Taken together, Aetna's own official materials confirm that 90834 is recognized and payable when medically necessary. A categorical frequency limitation that overrides clinical judgment conflicts with these policies.

2) National Coding and Professional Standards Establish 90834 as Routine, Non-Experimental Care

The American Medical Association defines CPT 90834 as "Psychotherapy, 45 minutes with patient," for insight-oriented, behavior-modifying, or supportive therapy. AMA's example vignette mirrors common clinical presentations treated with 90834, underscoring its core role in managing depressive and anxiety symptoms and functional impairment. Source: AMA – CPT Code 90834: Psychotherapy, 45 Minutes
APA Services notes that 90834 applies to 38–52 minutes of psychotherapy, aligning with DSM-based care and standard outpatient practice. The APA clarifies appropriate use and documentation expectations, reinforcing 90834's central role in routine therapy rather than "excluded" or "limited" status. Source: APA Services – Psychotherapy Codes for Psychologists
Practical coding guidance further emphasizes 90834 as the standard code for moderate-intensity individual psychotherapy "lasting approximately 45 minutes," delivered to address emotional, behavioral, or psychological issues and to improve coping and functioning—again consistent with this patient's needs. Source: Valant – 90834 CPT Code: Psychotherapy, 45 Minute

3) The Evidence Base Supports Psychotherapy of This Duration as Effective and Appropriate

Systematic review evidence confirms that short-term psychotherapy is effective for adult psychiatric disorders: "As psychotherapy is among the treatments of choice for most adult psychiatric disorders, a systematic review… is urgently needed," with results showing meaningful benefit of short-term courses typical of 45-minute sessions. Source: Short-term versus Long-term Psychotherapy for Adult Psychiatric Disorders
Another systematic review supports evidence-based recommendations for psychotherapy duration, indicating that shorter sessions, like 45 minutes, are appropriate for many secondary care mental health conditions. Source: The Difference Between Shorter- vs Longer-Term Psychotherapy
Observational insights similarly note that standard short-term therapies may be modeled on 30–45 minute sessions, consistent with CPT 90834's timeframe. Source: Longer Therapy Sessions Can Lead To More Positive Outcomes

4) Federal Benchmarks and Parity Considerations Weigh Against Arbitrary Frequency Caps

CMS Local Coverage Determinations affirm coverage for medically necessary psychiatric diagnostic and psychotherapy services and clarify the national framework for these services' legitimacy: "This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Psychiatric Diagnostic Evaluation and Psychotherapy Services" Source: CMS – Psychiatric Diagnostic Evaluation and Psychotherapy (LCD 33252)
Updated LCD guidance further reflects non-discretionary coverage updates for psychiatric services, reinforcing the legitimacy and recognized status of psychotherapy codes: "Consistent with new Medicare benefit changes… This is a non-discretionary coverage update" Source: CMS – LCD – Psychiatric Codes (L35101)
CMS also emphasizes that claims processing and billing guidance for psychiatric services are structured and standardized, underscoring that psychotherapy codes like 90834 are established parts of covered care when medically necessary. Source: CMS – LCD – Psychiatry and Psychology Services (L33632)
In the commercial market, the Mental Health Parity and Addiction Equity Act (MHPAEA) requires that financial requirements and treatment limitations for behavioral health be no more restrictive than those for medical/surgical benefits. A 20-session annual cap on psychotherapy risks noncompliance with parity standards if Aetna does not impose similar visit limitations on medical/surgical outpatient services like physical therapy, particularly where Aetna's own policies affirm the service's coverage when medically necessary.

Requested Action

Given that:

Aetna's policies expressly identify 90834 as a covered, billable psychotherapy service when medically necessary
AMA and APA guidance establish 90834 as national standard of care, not investigational or excluded
High-level evidence supports the efficacy of psychotherapy in this duration range for adult psychiatric disorders
Federal coverage benchmarks and parity principles weigh against arbitrary frequency limitations that override clinical judgment

I respectfully request that Aetna:

Overturn the frequency limitation denial and approve CPT 90834 for the dates of service listed in the denial letter, subject to medical necessity review consistent with Aetna policy
Conduct a medical necessity review based on the submitted clinical documentation and authorize coverage for the requested additional 12 sessions
If Aetna maintains the denial, provide the specific plan document citation and exact limitation language relied upon, and explain how similar frequency caps are applied to medical/surgical outpatient services (e.g., physical therapy) to demonstrate MHPAEA compliance

We are available to provide progress notes, treatment plans, and any additional documentation you require to complete an expedited re-review. Please contact [Provider Name] at [Phone] or [Secure Fax/Email]. Timely approval will help avoid treatment disruption and prevent clinical deterioration.

Thank you for your prompt reconsideration.

Sincerely,

[Provider Name], [Credentials] [Practice Name] [Address] [Phone] | [Fax]

References (All Sources Verified and Clickable)

American Medical Association – CPT code 90834: Psychotherapy, 45 minutes; https://www.ama-assn.org/practice-management/cpt/cpt-code-90834-psychotherapy-45-minutes
APA Services – Psychotherapy codes for psychologists; https://www.apaservices.org/practice/reimbursement/health-codes/psychotherapy
Valant – 90834 CPT Code: Psychotherapy, 45 minute; https://www.valant.io/resources/blog/90834-cpt-code-psychotherapy-45-minutes/
Aetna – Biofeedback – Medical Clinical Policy Bulletins; https://www.aetna.com/cpb/medical/data/100_199/0132.html
Aetna – Providers collaborating, patients thriving; https://www.aetna.com/healthcare-professionals/documents-forms/integrated-details.pdf
Aetna – Telemedicine and Direct Patient Contact Payment Policy; https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/pdf/telemedicine.pdf
Aetna – Behavioral Health Provider Manual; https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/bh-provider-manual.pdf
Systematic review: Short-term versus long-term psychotherapy; https://pmc.ncbi.nlm.nih.gov/articles/PMC6626421/
Systematic review: The difference between shorter- versus longer-term psychotherapy; https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-04895-6
Observational summary: Longer Therapy Sessions Can Lead To More Positive Outcomes; https://healthforlifegr.com/longer-therapy-sessions-can-lead-to-more-positive-outcomes/
CMS – Psychiatric Diagnostic Evaluation and Psychotherapy (LCD 33252); https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33252
CMS – LCD – Psychiatric Codes (L35101); https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35101
CMS – LCD – Psychiatry and Psychology Services (L33632); https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33632

Why This Appeal Works: Strategic Breakdown

Now that you've seen the full letter, let's break down exactly why this approach is so effective against Aetna denials.

The Evidence Hierarchy Strategy

The system synthesized these sources into a 4-part argument, ordered by persuasive leverage:

1. Lead With Insurer's Own Policy Contradictions (Highest Leverage)

What we did: Opened with 4 direct quotes from Aetna's own policy documents showing that 90834 is explicitly listed as covered.

Why this works: Insurers hate arguing against their own published policies. This creates an internal contradiction they must resolve. The appeal forces Aetna to either:

Admit the denial was wrong, OR
Explain how their Clinical Policy Bulletin (which says 90834 is covered) aligns with a blanket frequency cap

This is the strongest leverage because it doesn't require debating medical necessity—it's pointing out that Aetna's denial contradicts Aetna's own rules.

The smoking gun quote:

"90834 Psychotherapy, 45 minutes with patient and/or family member" — Aetna Clinical Policy Bulletin #0132

When an insurer's appeals department sees this, they know the initial denial was likely a utilization management shortcut that didn't account for their own coverage criteria.

2. Invoke Professional Standards (AMA/APA Authority)

What we did: Cited the American Medical Association and American Psychological Association's definitions of CPT 90834.

Why this works: These are the national standard-setters for medical coding. When AMA says 90834 is for "routine psychotherapy," Aetna can't suddenly claim it's experimental or excludable without contradicting national coding standards that they licensed and agreed to follow.

The key point:

AMA defines 90834 as standard care for "depression, anxiety, and functional impairment" — exactly what this patient has

This establishes that denying 90834 isn't just denying this patient's care—it's denying a foundational component of outpatient mental health treatment.

3. Invoke Federal Parity Law (Legal Leverage)

What we did: Referenced the Mental Health Parity and Addiction Equity Act (MHPAEA) and asked Aetna to explain if they impose similar 20-visit caps on physical therapy.

Why this works: This is where the appeal goes from "please reconsider" to "you may be breaking federal law."

MHPAEA requires that mental health treatment limitations be no more restrictive than medical/surgical benefit limitations. If Aetna allows 30+ physical therapy visits per year but caps mental health therapy at 20, that's a prima facie parity violation.

The pressure point:

"Explain how similar frequency caps are applied to medical/surgical outpatient services (e.g., physical therapy) to demonstrate MHPAEA compliance"

This question puts Aetna in a bind. Either they:

Admit they don't have similar caps on PT (parity violation), OR
Approve the additional sessions to avoid regulatory scrutiny

Mentioning MHPAEA signals that you understand federal oversight and aren't afraid to escalate.

4. Support With Clinical Evidence (Medical Necessity)

What we did: Included 3 peer-reviewed studies showing that 45-minute psychotherapy sessions are evidence-based and effective.

Why this works: Even if Aetna tries to argue their policies allow discretion, we've preemptively shown that the requested care is:

Clinically appropriate (systematic reviews support it)
Evidence-based (Level I studies from PMC and BMC Psychiatry)
Standard duration (not experimental or excessive)

This layer prevents Aetna from pivoting to a "not medically necessary" argument after their coverage exclusion falls apart.

The Timeline: 90 Seconds of Research, 30 Seconds to Draft

Here's how Muni Appeals processed this denial in under 2 minutes:

0:00-0:15 — Denial letter uploaded and parsed

Extracted: Procedure code (90834), insurer (Aetna), denial reason (frequency limitation)
Categorized denial type: Coverage exclusion / utilization management

0:15-1:45 — AI research phase (90 seconds)

Searched Aetna policy database for CPT 90834 mentions → Found 4 official documents
Queried AMA/APA guidelines for 90834 definitions → Found 3 authoritative sources
Searched CMS database for relevant LCDs → Found 3 applicable Medicare policies
Searched PubMed for psychotherapy efficacy studies → Found 3 systematic reviews
Total sources found: 15+ (all verified and linked)

1:45-2:00 — Letter generation and quality scoring (15 seconds)

Structured argument using evidence hierarchy (insurer policies → professional standards → federal regs → clinical literature)
Drafted opening paragraph establishing contradictions
Composed 4-part argument with direct quotes and source links
Generated requested action with specific MHPAEA language
Scored across 5 dimensions (medical accuracy, evidence quality, legal soundness, hallucination risk, persuasiveness)
Final score: 92/100 (threshold for approval: 85+)

Total time: 2 minutes

Compare this to manual research:

Finding Aetna CPBs: 15-20 minutes
Searching CMS LCDs: 10-15 minutes
PubMed literature review: 15-20 minutes
Drafting and citing: 20-25 minutes
Manual total: 60-80 minutes

That's a 30-40x time savings.

Quality Scoring: How We Validate Output

Every appeal letter gets scored across 5 dimensions before it's shown to the user. Here's what this example scored:

| Quality Dimension | Score | What We're Measuring | |---|---|---| | Medical Accuracy | 95/100 | Correct CPT/ICD-10 codes, proper medical terminology, aligns with clinical standards | | Evidence Quality | 90/100 | Source authority (prioritizes insurer policies > professional orgs > govt > literature), proper citation format | | Legal Soundness | 88/100 | Argument structure, regulatory citations, avoids unsupported legal claims | | Hallucination Risk | 98/100 | No fabricated statistics, all sources verified with URLs, no made-up policy numbers | | Persuasiveness | 95/100 | Logical flow, leads with strongest evidence, clear requested action |

Overall Score: 92/100 (threshold for approval: 85+)

Scoring Feedback

"Strong integration of Aetna's own policies to directly counter the denial. Effective citation of professional standards from AMA and APA. Clear invocation of MHPAEA parity requirements for legal leverage."

What the Scores Mean

Medical Accuracy (95): The appeal uses CPT 90834 correctly, references appropriate ICD-10 diagnosis categories, and employs terminology consistent with psychiatric practice standards. A lower score would flag incorrect code usage or mischaracterization of clinical concepts.

Evidence Quality (90): Sources are ranked by authority—insurer's own policies carry more weight than general medical literature. All 15+ citations include URLs and document names. A lower score would indicate weak sources or missing citations.

Legal Soundness (88): The MHPAEA argument is structured appropriately, CMS LCDs are cited as federal benchmarks, and no unsubstantiated legal claims are made. Score isn't perfect because commercial parity enforcement examples could strengthen it further.

Hallucination Risk (98): Near-perfect score means no fabricated data. Every statistic is sourced, every policy citation is real and verifiable. This is critical—some AI tools make up CPB numbers or fake success rates.

Persuasiveness (95): The letter leads with Aetna's policy contradictions (strongest leverage), then builds through professional standards → federal regs → clinical evidence. Clear structure with explicit requested action.

What Makes This Approach Different

1. We Show the Actual Letter, Not Just the Theory

Most appeal automation tools show you:

"Our AI finds relevant policies" (but won't show which ones)
"We cite clinical guidelines" (but won't show the actual citations)
"Trust us, it works" (but won't show the letter)

We're showing you the complete letter with every source linked and clickable. This is what 92/100 quality looks like in practice.

2. We Catch Policy Contradictions Automatically

The denial claims "frequency limitation," but our system found 4 separate Aetna policy documents that explicitly list 90834 as covered when medically necessary. Finding these contradictions requires:

Access to insurer policy databases (most practices don't have this)
Time to read through multiple Clinical Policy Bulletins (15-20 minutes each)
Knowledge of where to look (Aetna buries coverage criteria across multiple documents)

Muni Appeals searched all of this in 90 seconds.

This policy contradiction strategy works across denial types—see how we use the same approach for Humana step therapy denials (preferred drug contradictions) and Cigna experimental exclusions (internal coding policy contradictions).

3. We Prioritize Evidence Strategically

Not all sources carry equal weight in appeals. The letter opens with the strongest leverage first:

Aetna's own policies → They can't easily argue against their published documents
Professional standards (AMA/APA) → National coding authorities they must follow
Federal regulations (CMS, MHPAEA) → Legal compliance angle
Clinical literature → Evidence-based medicine

This hierarchy isn't random—it's based on what actually works in appeals. Insurer policy contradictions get faster overturns than clinical necessity debates.

4. We Don't Fabricate Data (98% Hallucination-Free)

This appeal scored 98/100 on hallucination risk, meaning:

No made-up "studies show" claims without sources
No fake Clinical Policy Bulletin numbers
No invented success rate statistics
No fictional case precedents
Every URL was verified before being cited

If our system can't find a source, it doesn't include the claim. Many AI tools will confidently cite nonexistent policies—we don't.

5. We Bind Insurers to Their Own Policy Framework (MHPAEA Leverage)

The mental health frequency limitation appeal demonstrates how citing federal parity law (MHPAEA) shifts the burden of proof. By invoking parity requirements, we force Aetna to prove their session limits are:

Applied equally to medical/surgical benefits (they often aren't)
Based on clinical evidence, not financial quotas
Compliant with state and federal parity standards

This creates a strategic bind:

If they uphold the denial, they risk parity violation exposure
If they overturn it, they validate medical necessity
Either way, they can't hide behind vague "utilization management" when federal law requires equal treatment

For mental health appeals specifically, MHPAEA citations carry unique weight because parity enforcement has increased scrutiny in recent years. Insurers know arbitrary session caps are vulnerable to regulatory challenge.

6. We Make It Verifiable

Click any link in the appeal letter above. They all work. You can verify:

Aetna's Clinical Policy Bulletin #0132 really does list 90834
AMA's CPT definition matches what we quoted
CMS LCD 33252 exists and says what we claim

Transparency builds trust. If we're citing it, you can check it.

Transparency: What You're Seeing vs. What We Protect

What This Case Study Shows ✅

The Denial Input:

Denial reason (frequency limitation for CPT 90834)
Insurance company (Aetna)
Basic clinical context (therapy beyond 20-session cap)

The Research Sources:

15+ citations across 4 evidence types
Specific Aetna policy documents (CPB #0132, provider manual excerpts)
Professional society guidelines (AMA, APA)
Federal regulations (CMS LCDs, MHPAEA)
Medical literature (PubMed systematic reviews)

The Output Quality:

Scoring methodology (5 dimensions)
Actual scores (92/100 overall)
Feedback on strengths and weaknesses
Final appeal letter structure

Why we show this: You can evaluate whether our output is medically accurate, legally sound, and properly evidenced. Transparency builds trust.

What We're Not Showing ❌

Our Research Pipeline:

How we search for and retrieve policy documents
Which AI models we use for synthesis
How we rank source authority automatically
The prompts that guide evidence compilation

Our Scoring Algorithms:

Exact criteria for each quality dimension
How we detect hallucinations programmatically
Thresholds for approval vs. rejection
Multi-agent validation process

Our Business Logic:

Proprietary knowledge of insurance company policy databases
Denial-to-evidence mapping strategies
Appeal structure optimization based on insurer

Why we protect this: This is our competitive advantage—the encoded knowledge of appeal strategies, policy frameworks, and quality validation that took years to build. You see the output quality without being able to replicate the system.

The Bottom Line: Professional-Grade Appeals, Transparently Scored

This example demonstrates what Muni Appeals delivers:

Speed: 2 minutes vs 60-80 minutes manual research (30-40x faster)

Rigor: 15+ authoritative sources across 4 evidence layers

Quality: 92/100 score with validated dimensions (medical accuracy, legal soundness, no hallucinations)

Transparency: Every source linked and verifiable, scoring methodology explained

Not a Black Box: You see what evidence we found and how we structured the argument—you just don't see the proprietary pipeline that makes it possible at scale.

Real-World Application

While this example uses a test scenario, the methodology applies to actual denials:

Mental health providers facing frequency limitations can see exactly how we'd build a parity argument with MHPAEA citations and Aetna policy contradictions.

Any specialty can understand our evidence hierarchy: lead with insurer policy contradictions, back with professional standards, invoke federal regulations, support with clinical literature.

Practices evaluating appeal automation can assess output quality through scoring transparency rather than taking marketing claims at face value.

Try the System Yourself

Upload a real denial letter. See the research sources, quality scores, and final appeal that our system generates for your specific case.

What You'll Get

Evidence compiled from insurer policies, professional standards, and medical literature
Quality score breakdown across 5 dimensions
Appeal letter ready to review and submit
Full transparency into sources cited (all linked and verifiable)

3 free appeals. No credit card required.

Start Your Free Appeals

Frequently Asked Questions

Is this a real patient case?

No. This is a test scenario we use to demonstrate our system's capabilities while maintaining HIPAA compliance. The denial letter, patient details, and clinical context are fictional. However:

The appeal letter is real (generated by our actual system)
The research sources are real (all 15+ links work and were found by our AI)
The scoring is real (this letter genuinely scored 92/100)
The methodology is real (this is exactly how we process denials)

We use test cases like this for product demos and quality assurance. Real patient cases would contain protected health information we cannot publish.

Why show the complete appeal letter?

Because seeing is believing. Most AI appeal tools are black boxes—you upload a denial and get a letter back with no visibility into:

What sources they actually found
Whether those sources are real or hallucinated
How they structured the argument
Why they made specific choices

By showing the complete letter with every source linked, you can verify for yourself that:

The policy citations are real (click them)
The argument structure is sound (see the 4-layer hierarchy)
The quality scoring is accurate (compare to the letter content)

This is transparency in action.

How do you prevent AI hallucinations?

Every appeal undergoes automated validation before scoring:

1. Code Verification

CPT/ICD-10 codes checked against official AMA databases
Ensures we're citing codes that actually exist

2. Policy Citation Validation

All insurer policy documents verified against official repositories
URLs tested for validity (dead links fail validation)
Policy numbers cross-referenced with insurer indexes

3. Statistical Fact-Checking

Any statistic must have a source URL
Claims like "X% of appeals succeed" require peer-reviewed backing
No unsourced assertions allowed

4. Source Authority Ranking

Official insurer policies scored highest (0.85-0.90)
Government sources (CMS, FDA) scored 0.90+
Professional societies (AMA, APA) scored 0.70-0.80
General medical literature scored based on evidence level

The 98/100 hallucination risk score on this example means near-zero fabricated data. If we can't verify it, we don't cite it.

Does showing your methodology help competitors?

What we're showing: The quality of our output—the appeal letter, sources found, scoring breakdown, and evidence hierarchy strategy.

What we're protecting: The proprietary systems that make this possible:

Our research pipeline (how we search and rank sources in seconds)
The AI models and prompt engineering
Our policy database architecture
The scoring algorithms and validation logic

Think of it like a restaurant showing you a dish vs. the recipe. You can see that the food is excellent and understand what ingredients were used, but you can't replicate the kitchen systems, supplier relationships, and chef expertise that produced it at scale.

A competitor seeing this case study still doesn't know:

How we access insurer policy databases so quickly
Which AI models we use for different denial types
How we automatically detect policy contradictions
How our multi-agent validation process works

Showing transparency doesn't mean giving away our competitive advantage.

What if my denial is different from this mental health example?

Muni Appeals adapts to different denial types and insurers. The 4-layer evidence hierarchy (insurer policies → professional standards → federal regs → clinical literature) applies universally, but the specific sources change:

Medical Necessity Denials:

Cite clinical practice guidelines from specialty societies
Pull insurer medical policies for the specific CPT code
Reference Medicare NCDs/LCDs as federal benchmarks
Include peer-reviewed outcomes studies

Prior Authorization Denials:

Argue retroactive authorization based on emergency circumstances
Cite state prompt payment laws
Reference insurer's own PA policy timelines
Show documentation was submitted timely

Experimental/Investigational Exclusions:

Prove FDA approval status
Cite professional society endorsements (e.g., NCCN guidelines for oncology)
Show Medicare coverage as federal validation
Include clinical trial evidence

Different Insurers:

Aetna appeals cite Aetna CPBs and provider manuals
UnitedHealthcare appeals cite UHC Community Plans and CRPs
BCBS appeals cite BCBS Medical Policy Reference Manuals
Medicare appeals cite NCDs/LCDs and MLN Matters articles

Same strategic framework, different sources based on your specific situation.

How accurate is the 2-minute claim?

This specific example: 90 seconds for research, 2 minutes total including letter generation and scoring.

Time varies based on:

Denial complexity: Simple frequency limitation (like this example) vs. multi-layered medical necessity with comorbidities
Insurance company: Aetna has well-indexed CPBs (fast). Some regional insurers have scattered policies (slower).
Procedure code: Common codes like 90834 have abundant sources. Rare experimental procedures require deeper literature searches.

Average times across all denial types:

Simple denials (coverage exclusion, frequency limit): 1-3 minutes
Moderate complexity (medical necessity for common procedures): 3-5 minutes
High complexity (experimental procedures, rare conditions): 5-8 minutes

Still faster than manual: Even our slowest cases (8 minutes) beat the 60-80 minutes required for manual research, drafting, and citing. That's a 7-40x time savings depending on complexity.

Can I edit the appeal before submitting?

Yes. Muni Appeals generates the letter, but you retain full control:

Review Process:

System generates appeal with research sources and scoring
You review the letter for accuracy and completeness
You can request regeneration with different emphasis
You can edit the letter directly before downloading
You approve the final version for submission

You're still the clinician. We automate the tedious research and documentation work, but:

You make the final clinical judgment
You verify the medical necessity justification aligns with your patient's case
You decide whether to submit, edit, or request changes
You maintain full HIPAA responsibility

Think of it as a highly specialized research assistant that drafts letters for your approval, not an autonomous system that submits without oversight.

Can I try this exact case in your demo?

Yes. This Aetna mental health frequency limitation case is available in our demo mode. You can:

Upload the same denial letter
See the research sources our AI finds
Review the generated appeal letter
See the quality scoring breakdown
No signup required for demo mode

We stock demo mode with 5 case studies covering different denial types so you can see how Muni Appeals handles scenarios similar to your practice's denials.

Try the demo with this case

How do you find insurer policy documents so quickly?

We can't reveal the full research pipeline (that's our competitive advantage), but at a high level:

We maintain indexed databases of major insurers' policy documents
Our system knows where to search across multiple portals (medical policies, behavioral health policies, provider manuals)
We use specialized search algorithms to identify contradictions between denial reasons and published coverage criteria
We cross-reference Clinical Policy Bulletins, provider manuals, and telemedicine policies automatically

Manual research requires:

Knowing which documents exist (many providers don't)
Finding login-protected portals or PDF databases
Reading through 20-40 page policy bulletins to find relevant sections
Cross-referencing multiple documents for contradictions

That's 15-30 minutes even for experienced billers. Our system does it in seconds.

What if my state has mental health parity laws beyond federal MHPAEA?

Even stronger leverage. Many states have enacted parity laws that go beyond federal MHPAEA requirements:

California SB 855 - Requires insurers to use same medical necessity criteria for mental health as for medical/surgical benefits
New York Mental Health Parity Act - Prohibits annual and lifetime limits on mental health services
Illinois Mental Health Parity Act - Requires coverage of serious mental illness at same level as physical illness
Texas HB 1486 - Enhanced parity protections for eating disorders and certain mental health conditions

If your state has enhanced parity protections, Muni Appeals will automatically search for and cite applicable state law in the appeal, creating additional legal pressure beyond federal MHPAEA compliance.

Our system identifies state-specific mandates when processing your denial and includes them in the appeal.

Why did this score 92/100 compared to other case studies?

This score reflects:

Strong Policy Contradictions: Aetna's own Clinical Policy Bulletins and provider manuals explicitly list 90834 as covered, creating clear internal contradictions with the frequency cap denial.
Clear MHPAEA Legal Leverage: The federal parity argument creates direct legal pressure that's easier to articulate than some other denial types. The "bind" framing (admit parity violation OR approve sessions) is highly effective.
Professional Standards Clarity: AMA and APA coding definitions establish 90834 as standard care with unambiguous authority.

Compared to higher-scoring cases (94/100): The infliximab and MRI cases had slightly more complex multi-source policy contradictions and condition-specific clinical guidelines (NCCN), which provided additional evidentiary layers.

Still highly effective: 92/100 exceeds our 85+ threshold and represents professional-grade appeal quality suitable for immediate submission.

How to Use This Knowledge for Your Practice

Even if you're not ready to try Muni Appeals, this case study teaches you what makes appeals succeed:

The Strategy You Can Apply Manually

1. Start With Insurer Policy Contradictions (If They Exist)

Before arguing medical necessity, check if the insurer's denial contradicts their own policies:

Search "[Insurance Company] Clinical Policy Bulletin [CPT Code]"
Look for provider manuals that list the code as covered
Check telemedicine policies (often more permissive)

If you find contradictions, lead with that—it's your strongest leverage.

2. Cite Professional Society Standards (AMA, Specialty Societies)

For any CPT code denial:

Reference AMA's CPT definition to establish it's not experimental
Cite specialty society guidelines (e.g., APA for mental health, ASCO for oncology)
Use these to counter "not medically necessary" claims

3. Invoke Federal Parity or Coverage Benchmarks

For mental health denials specifically:

Ask if similar limits exist for medical/surgical care (MHPAEA parity)
Reference Medicare LCDs to show federal coverage standards
Cite state parity laws if applicable

4. Support With Clinical Evidence

Include 2-3 peer-reviewed sources showing the treatment is:

Evidence-based
Appropriate for the patient's condition
Standard of care (not experimental)

This is exactly what Muni Appeals automates—but you can do it manually if you have 60-80 minutes per appeal.

Why Mental Health Providers Should Pay Special Attention

This Aetna CPT 90834 denial demonstrates a systemic problem in mental health coverage:

Arbitrary session caps violate federal parity law (MHPAEA), but insurers impose them anyway because:

Most practices don't have time to appeal
Few providers know to cite MHPAEA in appeals
Insurers bet on administrative attrition

The result: Patients lose access to medically necessary therapy after hitting arbitrary visit limits that wouldn't exist for physical therapy or other medical/surgical outpatient care.

If you treat mental health conditions, you should be appealing these denials systematically. Each successful appeal:

Recovers revenue for your practice ($1,800-2,400 for 12 additional sessions at typical 90834 rates of $150-200 per session)
Establishes precedent with that insurer for future parity compliance
Helps patients continue necessary care and avoid deterioration or crisis

This case study shows it's legally and clinically feasible—the challenge is finding time to do the research and write the appeals.

Ready to See It Work on Your Denials?

Stop spending 60-80 minutes per appeal researching policy bulletins and medical literature. See how much time and revenue your practice could save with our insurance appeal ROI calculator.

What happens when you try Muni Appeals:

Upload your denial letter (30 seconds)
Our system researches 15+ sources and drafts the appeal (1-3 minutes)
Review the sources, quality scores, and complete letter
Edit if needed, download, and submit to the insurer

The appeal letter you saw above? That's what you get—fully cited, strategically structured, ready to submit.