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For more than a decade, Joani Reisen has been using Concerta to treat her ADHD, but when she went to refill her prescription earlier this year, she learned her health insurance provider would no longer cover the essential medication. Despite support from her doctors, her appeals were denied twice, and she was told the drug was classified as “experimental.” Reisen explains that Concerta helps her focus and the generic version left her feeling unwell and unable to run her business.
Fed up with the appeals process, Reisen turned to Counterforce Health, an AI platform trained on successful appeal cases that creates customized appeal letters for free. The system, developed with support from the NIH and the University of Pennsylvania, generated an 11-page letter that Reisen submitted to the Pennsylvania Insurance Commission. Counterforce co-founder Neal Shah says the tool makes appeals faster and easier, and that patients often succeed when they challenge insurance denials.
On her third appeal, Reisen’s medication was approved, although her insurer says the original denials only happened because a reviewer overlooked her official ADHD diagnosis, clarifying that AI didn’t influence their final decision. The insurer adds that they’re reviewing the error, while Reisen hopes her story will help others learn about available tools to fight coverage denials.