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Bone: when insurers say no, reviewers often say yes
In 58 published external-review decisions involving bone, independent physician reviewers overturned the insurer’s denial 56.9% of the time.
Published decisions
58
2001–2026
Overturned
56.9%
33 denials reversed
Most-fought treatments for bone
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Chemotherapy | 7 | 71.4% |
| PET Scan | 6 | 50% |
| Radiation Therapy | 5 | 80% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 29 | 55.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 29 | 58.6% |
Typical time to a decision
7 days
Most land between 4 and 16 days
Handled as urgent
74.1%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Findings: The physician reviewer found that The patient requested authorization and coverage for a Ossur Rheo microprocessor knee and Ottoback Maverick Comfort AT prosthetic foot.Current literature regarding the benefits of microprocessor-aided prosthetic knees relative to prosthetic knees without microprocessor-aided control is largely mixed and based on small patient numbers with low-quality data. A study indicated that there is a lack of high quality evidence showing improvement with microprocessor-aided prosthetic knee devices on the risk of falls and gait parameters over prosthetic knee devices without computer control. Further, the studies promoting motor-processor controlled knees are of low quality.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for special cold therapy cryoablation. Findings: The physician reviewer found that This patient’s records document that she is being treated for neoplasm of bone. The provider noted that the patient presented with a right talus bone lesion. X-rays of the right ankle showed a bone lesion in her right talus. The patient’s physical examination revealed right ankle with medial swelling, tenderness to palpation at the medial ankle, and limited range of motion due to stiffness and pain. The patient’s provider has recommended treatment with cryoablation.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician 1: The patient is a 14-year-old male who was diagnosed with stage IV alveolar rhabdomyosarcoma in March 2004. At that time he apparently had a large mass in his gluteal region, involvement of much of his spine, and involvement of his bone marrow. PET scan at that time showed multiple additional areas of cancer, multiple bones, bone marrow, and lymph nodes.The patient was treated with intensive chemotherapy. The current status of his disease is unknown. He has apparently recently undergone MRI of his entire spine, as well as essentially total body CT scanning. A PET scan has been requested, which has been denied by the Health Plan on the basis it is considered investigational.The usefulness of PET scanning in oncology is rapidly expanding as it has proven very beneficial in a wide variety of cancer types in terms of initial staging, evaluation of therapy, and re-staging.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiation therapy for treatment of the enrollee who has a history of lung cancer. Findings: The physician reviewer found that The requested services are not medically necessary for treatment of this patient’s medical condition. SBRT, delivering high fractional doses in 4-5 fractions, is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. SBRT can be considered in select patients with oligometastatic bone metastases.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for bone was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.