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High Cholesterol: when insurers say no, reviewers often say yes
In 18 published external-review decisions involving high cholesterol, independent physician reviewers overturned the insurer’s denial 11.1% of the time.
Published decisions
18
2001–2026
Overturned
11.1%
2 denials reversed
Most-fought treatments for high cholesterol
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Advanced Lipoprotein Testing | 4 | 0% |
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. | 9 | 11.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 11.1% |
Typical time to a decision
21 days
Most land between 15 and 21 days
Handled as urgent
11.1%
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
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) of the heart. Findings: The physician reviewer found that records provided for review support that this patient has a borderline 10-year arteriosclerosis cardiovascular disease risk. Based on current published guidelines, moderate intensity statin therapy may be considered for this level of low density lipoprotein (LDL) cholesterol with a borderline risk profile. The CT of the heart was indicated to assess the patient’s coronary calcium score, which is a risk-enhancing factor that would reclassify the patient to a higher risk score and support treatment with cholesterol lowering statin therapy. Given the patient’s coronary calcification score of zero was helpful to determine whether the patient required long-term treatment with statin therapy.
A 64-year-old male enrollee has requested Zetia 10mg for the treatment of his high cholesterol. Findings: The physician reviewer found that the patient has been taking Crestor at the maximum dose. This dose of Crestor is stronger than or equivalent to Lipitor 80mg or simvastatin 80mg per day (formulary alternatives). There is no medical advantage to requiring that the patient switch to the maximum dose of the formulary statin to prove that he will not achieve his target. In this case, Zetia is medically appropriate for treatment of this patient.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a follow-up lipoprotein(a) test. Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations, including the American College of Cardiology (ACC) and the American Heart Association (AHA). These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2 (Lp-PLA2), subclassifications of low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), lipoprotein(b), C-reactive protein, high-sensitivity C-reactive protein (CRP), insulin, insulin resistance, fibrinogen, genetic testing, and homocysteine.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. There is a lack of clinical studies in current medical literature demonstrating that strategies to correct the residual risk potentially identified by novel lipoprotein testing, such as the service at issue, will further reduce cardiac risk. It remains unclear if that such testing adds significant actionable information to what is already known from a fasting lipid panel.
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 high cholesterol 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.