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Dizziness Vertigo: when insurers say no, reviewers often say yes
In 22 published external-review decisions involving dizziness vertigo, independent physician reviewers overturned the insurer’s denial 50% of the time.
Published decisions
22
2001–2026
Overturned
50%
11 denials reversed
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. | 13 | 38.5% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 62.5% |
Typical time to a decision
20 days
Most land between 13 and 22 days
Handled as urgent
13.6%
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: A 67-year-old female enrollee has requested authorization and coverage for functional endoscopic sinus surgery and septoplasty.. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollee’s deviated nasal septum; nasal turbinate hypertrophy; chronic sinus infection; chronic sinusitis; and nasal polyps.At issue in this case is whether the requested functional endoscopic sinus surgery and septoplasty are medically necessary for treatment of the patient’s medical condition.Per researchers, nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their etiology is unknown.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vestibular rehabilitation services. Researchers report that in persistent postural-perceptual dizziness (PPPD) and related disorders, vestibular rehabilitation combined with cognitive-behavioral therapy (CBT), and possibly supported by medication, may help patients escape a cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in daily life. The authors note that PPPD may be managed with effective communication and tailored treatment strategies including specialized physical therapy such as vestibular rehabilitation, serotonergic medications, and CBT.
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 alternative surgical positioning, without laying the patient flat and without inverting the patient, during total hysterectomy with bilateral salpingo-oophorectomy surgery. Laparotomy, laparoscopic, and robotic hysterectomy are all surgical approaches for the removal of the uterus. Several factors should be considered in determining which approach to select, including the indication for the hysterectomy, the size and position of the uterus, the presence of other pelvic pathologies, patient factors, and surgeon expertise. Laparotomy involves a larger abdominal incision and is generally reserved for situations when laparoscopy is not feasible. Laparoscopic hysterectomy is minimally invasive and is associated with a shorter hospital stay, less postoperative pain, and faster recovery.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan or magnetic resonance spectroscopy (MRS) or angiography and magnetic resonance angiography (MRA) scan. The Health Plan has denied this request indicating that the requested diagnostic procedures are not medically necessary for evaluation of the enrollee’s dizziness. The requested for CT scan, MRS or angiography and MRA scan are not medically necessary for evaluation of the patient’s medical condition. In this case, the patient has a history of dizziness without evidence of other neurologic deficits. Symptoms have been present for at least four years, and the patient has been seen by a neurologist, who did not detect an underlying disease. In addition, the patient underwent an MRI of the brain in 2016 which was negative.
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 dizziness vertigo 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.