Our Data & Sources
Every number and coverage rule on Medterpret comes from public federal data or peer-reviewed research. This page shows exactly where each figure comes from.
The numbers on our home page
Every statistic on our home page maps to a verified stat card in our Medicare knowledge base. Here is each card, with the population it describes. Words in [brackets] replace internal file names.
Share of MA PA denials that are appealed, 2024
On our home page: “1 in 10 prior-authorization denials are ever appealed.”
- Value
- 11.5% (KFF prose) / 12.2% (KFF chart dataset). Trend: 7.5% (2019), 11.7% (2023), 11.5% (2024). Roughly 472,000 appeals in 2024 (derived: ~4.1M denials × 11.5% — KFF does not state the absolute appeal count).
- Population / denominator
- Of denied MA prior-authorization requests (the ~4.1 million 2024 denials), the share that were appealed to the plan
- Period
- CY2024 (trend 2019–2024)
- Geography
- United States
- Source
- KFF analysis of CMS contract-level data — KFF, January 28, 2026; chart dataset cPTdA/6.
- Verification status
- VERIFIED (Tier 1), 2026-07-07
Share of appealed MA PA denials that are overturned, 2024
On our home page: “8 in 10 of those appeals are overturned, fully or in part.”
- Value
- 80.7% overturned fully or partially (prose and chart dataset match exactly). Overturn rate exceeded 80% every year 2019–2024 (“more than eight in ten” per KFF); highest documented year is 83.2% in 2022 (KFF’s CY2022 analysis, pub. Aug 8, 2024).
- Population / denominator
- Of MA prior-authorization denials that were appealed (Level-1 plan reconsideration) — NOT of all denials, and NOT a Level-2 rate
- Period
- CY2024 (trend 2019–2024)
- Geography
- United States
- Source
- KFF analysis of CMS contract-level data — KFF, January 28, 2026; chart dataset QooQc/4.
- Verification status
- VERIFIED (Tier 1), 2026-07-07
Liability without a valid ABN (a rule, not a statistic)
On our home page: “$0 is what you owe on a “not reasonable and necessary” denial if the provider never had you sign a valid ABN. It's the law.”
- Rule
- Without a valid ABN (none issued, or issued but invalid) where notice was required: the beneficiary owes NOTHING on a “not reasonable and necessary” denial. The provider is not permitted to bill the beneficiary, and under SSA §1879 the provider “will not be paid, either by Medicare or the beneficiary.”
- Applies to
- Original Medicare only. ABNs have no legal effect in Medicare Advantage.
- Does not apply to
- Services Medicare excludes by law. Medicare’s manual lists “Routine physicals and most screening tests (§1862(a)(7) of the Act)” among the denials where “the LOL provision does not apply” (Medicare Claims Processing Manual, Pub. 100-04, Ch. 30 §20.2). You owe those even without an ABN.
- How the denial reads on your MSN
- Not reasonable and necessary: “The information provided does not support the need for this service or item.” Routine exam: “Routine examinations and related services aren’t covered.” (CMS Complete MSN Message List, 07-30-26, messages 15.4 and 18.1.)
- Source
- Social Security Act §1879 (42 U.S.C. §1395pp); 42 CFR §§411.400, 411.402, 411.404, 411.406; Medicare Claims Processing Manual, Chapter 30 (CMS).
- Verification status
- Tier 1 rule, 2026-07-07; citation corrected 2026-09-27 (§411.408 governs non-assigned physician refunds, not assigned lab claims)
Average laboratory markup over the Medicare CLFS rate
On our home page: “392% average lab markup over what Medicare pays (median 250%), across 97,714 provider-service records: 2023 submitted charges vs. the 2026 Clinical Laboratory Fee Schedule.”
- Value
- 391.8% mean markup over the Clinical Laboratory Fee Schedule rate (published and rounded site-wide as 392%); median 250.2%. Equivalently, the average laboratory bills about 4.9x what Medicare pays.
- Population / denominator
- 97,714 records, where one record is one (laboratory NPI x HCPCS code) row from the CMS “Medicare Physician & Other Practitioners - by Provider and Service” public use file, CY2023, restricted to (a) the laboratory-organization subset loaded into [our lab-provider database] (3,028 NPIs; 2,472 appear in the matched set; LabCorp, Quest, BioReference and hospital laboratory systems dominate) and (b) HCPCS codes carrying a CLFS rate (1,207 codes). Markup = (average submitted charge / CLFS rate) - 1. The mean is UNWEIGHTED across records - it is the average markup of a provider-code combination, not of a service. The records cover 230,547,108 services; weighting by service volume instead gives 481.1%, a different and also-true statistic that is not the published number.
- Period
- CY2023 submitted charges compared against the 2026 CLFS. Two clocks, both of which must be labeled wherever this appears; no prior-year CLFS is stored locally, so a same-year comparison is not currently possible.
- Geography
- United States - 50 states plus DC and Puerto Rico
- Source
- CMS Medicare Physician & Other Practitioners - by Provider and Service, CY2023 vs CMS Clinical Laboratory Fee Schedule 2026. A Medterpret analysis of CMS data [derivation script on file].
- Caveats
- (1) “submitted charge” is what the lab billed, not what anyone paid - on a covered Part B lab test Medicare pays the CLFS rate and the beneficiary owes $0, so this markup bites in ABN, self-pay and denied-claim situations, not on covered claims; (2) CMS suppresses records representing fewer than 11 beneficiaries, so low-volume provider-code combinations are absent by construction (minimum observed = 11, matching the rule); (3) the script that built [our lab-provider database] is not in the backend repo, so the lab-subset criterion is inferred from the data, not read from a loader.
- Verification status
- VERIFIED (Tier 1 - own derivation over a federal dataset, independently reproduced 2026-09-21)
Deadlines we quote
Appeal and decision deadlines are set by regulation. Where our pages state one, this is the rule behind it.
- Original Medicare, 120 daysto ask for a redetermination, counted from when you get the Medicare Summary Notice (presumed 5 days after the date on it). 42 CFR §405.942.
- Medicare Advantage, 60 daysto ask your plan for a reconsideration, counted from when you get the denial notice (presumed 5 days after the date on it). 42 CFR §422.582.
- Medicare Advantage prior-authorization decisions: 7 calendar days for a standard request and 72 hours for an expedited one, since January 1, 2026. CMS-0057-F.
- Medicare Advantage denial noticesmust state the specific reason for the denial. 42 CFR §422.568; CMS-0057-F.
Important: our coverage tools are Original Medicare only
The coverage rules and rates in Precheck, Test lookup and Find a lab apply to Original Medicare (also called Traditional Medicare or Medicare Fee-for-Service — Parts A and B), administered directly by the federal government.
If you are enrolled in a Medicare Advantage plan (Part C) — a plan offered by a private insurance company — your coverage rules, reimbursement rates, and prior authorization requirements may be different. Medicare Advantage plans must cover what Original Medicare covers, but they can add requirements of their own, such as prior authorization and provider networks. Contact your plan directly for coverage and cost information.
Not sure which type of Medicare you have? Check your insurance card: if it says “Medicare Advantage,” “Medicare Part C,” or shows a private insurer’s name (Humana, UnitedHealthcare, Aetna, BCBS, etc.), you have a Medicare Advantage plan.
Where Our Data Comes From
Medterpret draws on three data sets, all published by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare:
1. Local Coverage Determinations (LCDs)
LCDs are coverage policies set by each regional Medicare contractor. They specify which diagnosis codes (ICD-10) justify a lab test for Medicare reimbursement. When you upload a lab order, Medterpret checks the CPT codes against the LCD rules that apply in your region.
Source: Centers for Medicare & Medicaid Services, Local Coverage Determinations database
2. National Coverage Determinations (NCDs)
NCDs are nationwide coverage policies issued by CMS directly. They take precedence over LCDs for the tests they cover. Our tool checks both.
Source: Centers for Medicare & Medicaid Services, National Coverage Determinations database
3. Clinical Laboratory Fee Schedule (CLFS)
The CLFS is what Medicare actually pays for each lab test — the official reimbursement rate. CMS sets and publishes this annually. The Medicare rate shown for each test on our site is pulled live from our database so it always reflects the current year.
Source: Centers for Medicare & Medicaid Services, Clinical Laboratory Fee Schedule (CLFS)
Statistics from Our Blog Posts
The statistics cited in our blog posts come from peer-reviewed journals, federal agencies, and non-profit health policy organizations:
- 80%+ of medical bills contain at least one error — Pat Palmer / Medical Billing Advocates of America via Healthline
- 53% of Medicare complainants said the billed amount was inaccurate — CFPB Issue Spotlight, May 2023
- ~75% who contacted a billing office had the error corrected — JAMA Health Forum 2024 via NBC News
- CBC hospital avg $401 vs Medicare $7.77; CMP $957 vs Medicare $14.35 — Cureus/PMC 2024, 42 Florida hospitals
- More than 8 in 10 appealed Medicare Advantage prior-authorization denials overturned, fully or in part, every year 2019–2024 — KFF, January 2026
- 76% who negotiated got help or had the bill reduced or canceled — JAMA Health Forum 2024 via NBC News
- Cash prices varied up to 243× between Tennessee hospitals — JALM, February 2025
- ABN rules and provider liability — Centers for Medicare & Medicaid Services; Center for Medicare Advocacy
- Negotiating medical bills — Solace Health
A Note on Data Currency
Medicare rates on this site update automatically whenever CMS changes the Clinical Laboratory Fee Schedule — you’re always seeing the current rate. LCD and NCD coverage rules are updated as CMS issues new determinations.
Last updated: September 2026. Questions about our methodology? Contact us.