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Injury: when insurers say no, reviewers often say yes
In 59 published external-review decisions involving injury, independent physician reviewers overturned the insurer’s denial 33.9% of the time.
Published decisions
59
2001–2026
Overturned
33.9%
20 denials reversed
Most-fought treatments for injury
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| MRI | 9 | 33.3% |
| Emergency Room | 6 | 33.3% |
| Admission | 3 | 100% |
| Inpt Admission | 3 | 0% |
| Physical Therapy | 3 | 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. | 46 | 32.6% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 8 | 37.5% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 40% |
Typical time to a decision
16 days
Most land between 7 and 21 days
Handled as urgent
28.8%
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 authorization and coverage for a four corner fusion surgery with compression FT screws for treatment of the enrollee who has a history of left wrist pain. Findings: The physician reviewer found that the submitted documentation supports the requested services in this patient’s case. A study indicated that four corner fusion had been shown to be a reliable option of treatment of wrist arthritis. They concluded that four corner fusion using headless retrograde headless screws demonstrated a low complication rate and high fusion rate, and could therefore be considered a reliable surgical technique.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services for treatment of an emergency medical condition. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.” A screening examination in an e…
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
A 21-year-old male has requested approval for past services provided on an urgent basis for treatment of his foot fracture. Findings: The physician reviewer found that the patient sustained fractures of the right foot while outside of the Plan’s service area. The patient was involved in a motor vehicle accident and was seen in an emergency room where x-rays were obtained. He was told that he had suffered a contusion, and was discharged. Because of pain with ambulation, the patient returned to the emergency room eight days later and a CT scan was obtained. The patient was then placed in a splint and on crutches. For a few days, he had increasing calf pain. On examination, there was tenderness, no swelling, and intact neurovascular functions.
The patient is a 30-year-old male who was noted as of 3/23/03 to be in a vegetative state. He was responsive to noxious stimuli. He had no eye opening and followed no commands. Per the physician’s note of 4/12/03, the patient had spontaneous eye opening, was non-verbal, and had increased tone in all four extremities. Upon admission to an eight-week coma rehabilitation program on 4/22/03, the patient exhibited the following: spontaneous eye opening, no tracking, disconjugate gaze, inability to follow directions, decorticate posturing on the left side, decerebrate on the right side, and no spontaneous motor movement. The patient was returned to acute care on 5/2/03 for repair of a colon perforation and returned to rehabilitation on 5/9/03. He remained at the same level of functioning. As of 7/16/03, there was no change in the patient’s condition.
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 injury 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.