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Cirrhosis: when insurers say no, reviewers often say yes
In 29 published external-review decisions involving cirrhosis, independent physician reviewers overturned the insurer’s denial 75.9% of the time.
Published decisions
29
2001–2026
Overturned
75.9%
22 denials reversed
Most-fought treatments for cirrhosis
What insurers denied — and how those fights ended.
Typical time to a decision
17 days
Most land between 5 and 21 days
Handled as urgent
41.4%
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
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was treated for alcohol withdrawal with a Librium taper. The patient has continued to complain of agitation, tremors, and irritability.
Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography angiography (CTA) for evaluation of the enrollee’s end stage liver cirrhosis awaiting liver transplant. Findings: The physician reviewer found that the requested diagnostic procedure has been established as medically necessary for evaluation of the patient’s medical condition. CTA of the chest is a radiologic examination of the structures in the chest that allows the clinician to see highly detailed vascular anatomy. The American College of Cardiology (ACC) recommends coronary angiography prior to liver transplantation when the patient has greater than two risk factors due to increased risk of poor outcomes in the transplanted patient with significant coronary artery disease (Raval, et al).
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was treated for withdrawal during hospitalization and the records indicate that he has been able to remain sober. The patient’s withdrawal needs can be safely managed in a Level 3.1 setting.
The patient is a 57-year-old man with hepatitis C genotype 1 and cirrhosis. He has failed treatment with interferon and ribavirin due to side effects including bone marrow and psychiatric effects. He has a long list of complicating diagnoses including hypertension and cholelithiasis. The patient’s provider has recommended the patient begin treatment with ribavirin monotherapy. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patient’s medical condition.The issue of treatment failure and the benefit of ongoing therapy with interferon or ribavirin as a method to suppress inflammation has been addressed in the published guidelines of the American Association for the Study of Liver Disease.
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 cirrhosis 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.