Home / Conditions / Brain Injury Concussion
Brain Injury Concussion: when insurers say no, reviewers often say yes
In 59 published external-review decisions involving brain injury concussion, independent physician reviewers overturned the insurer’s denial 45.8% of the time.
Published decisions
59
2001–2026
Overturned
45.8%
27 denials reversed
Most-fought treatments for brain injury concussion
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Admission | 7 | 85.7% |
| Inpt Admission | 6 | 33.3% |
| Trau Brain Inj Prog | 6 | 66.7% |
| Non Emerg Med (NEMT) | 6 | 0% |
| Physical Therapy | 5 | 0% |
| SCP Consult Refer | 3 | 66.7% |
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. | 51 | 49% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 25% |
Typical time to a decision
12 days
Most land between 6 and 21 days
Handled as urgent
44.1%
Expedited when a delay would cause harm
Recent direction
Rising
40.7% → 50% overturned, last three years
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 has requested authorization and coverage for full day speech, physical, and occupational therapies performed for up to four hours per day, five days per week. Current medical literature supports the use of rehabilitation in the context of traumatic brain injury (TBI). Researchers conclude regarding the effects of physical therapy interventions on balance impairments in individuals with TBI, “The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged dimensional rating system. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (A–Stressors, and B-Supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan. Researchers define traumatic brain injury (TBI) as an alteration in brain function, or other evidence of brain pathology, caused by an external force. TBI encompasses a broad range of pathologic injuries to the brain, of varying clinical severity, that result from head trauma. Researchers note that in patients with mild TBI, head computed tomography (CT) without contrast is the most appropriate examination choice. Head magnetic resonance imaging (MRI) without contrast may be sensitive in detecting intracranial injury that is occult on CT, such as subtle blood products or secondary signs of injury like edema.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient acute rehabilitative care that includes one-on-one pool therapy.Functional impairments due to traumatically acquired brain insults can improve with time, i.e., natural recovery processes. Researchers state that these impairments are also generally amenable to rehabilitation interventions. According to medical literature, the standard of care for rehabilitation in the setting of acute traumatic brain injury includes efforts to foster neurological recovery, mitigate risk of complications, improve function, advise on appropriate durable medical equipment, train family members/caregivers, and aid in the transition back to the community when feasible.
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 brain injury concussion 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.