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Insurer Appeal Outcomes

insurer_appeal_outcomes
Read-onlyIdempotent

Does appealing a denied health-insurance claim work? Marketplace issuers ranked by the share of appeals that were OVERTURNED in the patient's favour, plan year 2026. Answers "is it worth appealing a denied claim", "what percentage of insurance appeals succeed", "how often does reverse a denial", and which insurer most often changes its mind. Returns internal appeals (decided by the insurer itself) and external appeals (decided by an independent reviewer) separately, with how many were filed, how many were overturned, and the overturn percentage — the two differ a lot and the external number is the independent one. Sourced from the CMS Transparency in Coverage Public Use File; covers HealthCare.gov states only, so state-run exchanges such as California and New York are not present.

Input Schema

TableJSON Schema
NameRequiredDescriptionDefault
limitNoHow many issuers to return (default 20, max 200).
orderNo"highest" (default) ranks the most-overturned first; "lowest" ranks the least.
stateNoTwo-letter US state code to filter by, e.g. "TX". Omit for all states.
marketNoRestrict to issuers participating in "medical" / "QHP", "dental" / "SADP", or "SHOP". Selects issuers rather than splitting their figures. Omit for all.
appeal_typeNo"internal" (default, decided by the insurer) or "external" (decided by an independent reviewer).

Schema Changelog

Changes observed during successful MCP inspections.

  1. First observed

TDQS

A4.3/5.0
Behavior5/5

Does the description disclose side effects, auth requirements, rate limits, or destructive behavior?

Beyond the safe read-only/idempotent annotations, the description adds valuable behavioral detail: it returns internal and external appeals separately, explains that external appeals are decided by an independent reviewer, and notes that the two differ substantially. It also discloses the data source and the plan-year period (2026) and calls out coverage limitations for state-run exchanges. No contradiction with the annotations.

Agents need to know what a tool does to the world before calling it. Descriptions should go beyond structured annotations to explain consequences.

Conciseness4/5

Is the description appropriately sized, front-loaded, and free of redundancy?

The description is longer than necessary but almost every sentence earns its place: ranking criterion, use-case questions, internal/external breakdown, source provenance, and coverage caveat. The opening question phrasing is a bit informal and front-loads usefulness rather than a crisp return contract, so it earns a 4 rather than a 5.

Shorter descriptions cost fewer tokens and are easier for agents to parse. Every sentence should earn its place.

Completeness5/5

Given the tool's complexity, does the description cover enough for an agent to succeed on first attempt?

For a read-only, non-destructive, open-world ranked lookup, the description covers the essential facts an agent needs: output metrics (filed/overturned/percentage, internal vs external), data source, geographic coverage, and relevant caveats. Since the schema covers parameter syntax completely and the annotations cover safety semantics, nothing critical is missing for correct invocation.

Complex tools with many parameters or behaviors need more documentation. Simple tools need less. This dimension scales expectations accordingly.

Parameters4/5

Does the description clarify parameter syntax, constraints, interactions, or defaults beyond what the schema provides?

The schema schema already describes all five parameters, so the baseline is a solid 3; the description adds extra meaning by elaborating the appeal_type distinction (internal insurer-decided versus independent external review) and by giving the real-world implication that external numbers are the independent ones. It does not repeat schema wording, and the state caveat helps interpretation of the state parameter.

Input schemas describe structure but not intent. Descriptions should explain non-obvious parameter relationships and valid value ranges.

Purpose4/5

Does the description clearly state what the tool does and how it differs from similar tools?

The description clearly states that this tool ranks marketplace issuers by share of appeals overturned, which is a specific resource and computation. It differentiates itself from sibling denial tools by focusing on appeal outcomes rather than denial rates, though it does not name those siblings explicitly. The listed example questions ('is it worth appealing a denied claim', 'what percentage of insurance appeals succeed') further pin down its purpose.

Agents choose between tools based on descriptions. A clear purpose with a specific verb and resource helps agents select the right tool.

Usage Guidelines4/5

Does the description explain when to use this tool, when not to, or what alternatives exist?

The description gives explicit usage context by enumerating the exact questions the tool answers, such as whether appealing a denial is worthwhile or how often a particular insurer reverses denials. It also gives a clear exclusion: state-run exchanges like California and New York are not covered. It does not, however, explicitly say when to prefer this over insurer_denial_rates or other sibling tools.

Agents often have multiple tools that could apply. Explicit usage guidance like "use X instead of Y when Z" prevents misuse.

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