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Dry Eyes: when insurers say no, reviewers often say yes
In 13 published external-review decisions involving dry eyes, independent physician reviewers overturned the insurer’s denial 61.5% of the time.
Published decisions
13
2001–2026
Overturned
61.5%
8 denials reversed
Most-fought treatments for dry eyes
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Anti-inflammatories | 5 | 100% |
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. | 10 | 80% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 0% |
Typical time to a decision
17 days
Most land between 5 and 21 days
Handled as urgent
38.5%
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 Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lower eyelid blepharoplasty. The records provided for review document that this patient has a history of functional epiphora or excessive eye tearing. The patient’s provider has recommended a lower eyelid blepharoplasty. One study stated that “Though most cases of watering are due to non-patency in the lacrimal outflow pathway, others like eyelid and adnexal disorders and corneal and ocular surface pathology can also manifest as watering…In functional dysfunctions, the lacrimal outflow pathway is anatomically patent, but there is a failure of lacrimal pump mechanisms.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Restasis cyclosporine eye drops. Findings: In a systematic review to evaluate the safety and efficacy of topical cyclosporine in treating patients with dry eye syndrome, a study concluded that twice daily application significantly improved both objective and subjective outcomes. Another study notes that there is consistent evidence of objective improvements in chronic dry eye disease with the use of cyclosporine ophthalmic emulsion 0.05%. Patients with recalcitrant dry eye disease underlying inflammation are most likely to respond to this medication.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for intense pulse light (IPL) treatment. This is a patient with dry eye syndrome (DES), bilateral blepharitis (eyelid inflammation), keratoconjunctivitis sicca (dryness of the membrane that lines the eyelids and covers the white of the eye, and the clear layer in front of the iris and pupil) and meibornian gland dysfunction (MGD or lack of adequate oil secretion in tears). The provider reported that the patient’s visual acuity is 20/30 in the right eye and 20/20 in the left eye. The patient experiences a little DES improvement with topical cyclosporine (Restasis) eye drops, preservative-free artificial tears (PFATs), fluorometholone (FML) steroid eye drops, and nightly eye ointment.
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for TearCare procedure. The American Academy of Ophthalmology (AAO) Preferred Practice Pattern (PPP) guidelines do not discuss the TearCare procedure for the treatment of patients with dry eye syndrome. A report by the AAO on thermal pulsation noted that high-quality independent studies are needed to assess the long-term benefits of this intervention. Similarly, the AAO PPP guidelines on the treatment of patients with blepharitis or meibomian gland dysfunction state that “Although there have been industry-sponsored studies, independent, randomized clinical trials have yet to be performed to assess efficacy or superiority of any one of these treatments over another.” A meta-analysis reported that LipiFlow, which is a thermal pulsation treatment similar to TearCare, performs similarly to other commonly used dr…
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 dry eyes 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.