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Labral Tear: when insurers say no, reviewers often say yes
In 18 published external-review decisions involving labral tear, independent physician reviewers overturned the insurer’s denial 44.4% of the time.
Published decisions
18
2001–2026
Overturned
44.4%
8 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. | 12 | 41.7% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 6 | 50% |
Typical time to a decision
12 days
Most land between 3 and 21 days
Handled as urgent
44.4%
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 authorization and coverage for hip arthroscopy with labral repair, acetabuloplasty and femoroplasty. Findings: The physician reviewer found that femoroacetabular impingement results from bony morphologic abnormalities of the hip joint that result in abnormal contact during motion. Patients with femoroacetabular impingement present with chronic, deep, or aching anterior groin pain most commonly in the sitting position, or during or after activity. Patients might also experience occasional sharp pains during activity. Diagnosis of femoroacetabular impingement should be confirmed with radiography. Femoroacetabular impingement can be managed conservatively with rest, modification of activities, medications, and physiotherapy, or with surgical intervention.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for a magnetic resonance imaging (MRI) of the right hip.Per the American College of Radiology (ACR) guidelines, the requested magnetic resonance imaging (MRI) of the right hip is medically necessary for further evaluation of this patient. The ACR guidelines reveal that MRI is currently the reference standard for the evaluation of labral pathology. Further, the ACR guidelines indicate that for the evaluation of chronic hip pain with suspected labral tear and negative radiographs, an MRI is considered appropriate.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right hip arthroscopy with femoroplasty and hip arthroscopy with labral repair. Researchers report, “Labral tear is generally secondary to femoroacetabular impingement, trauma, dysplasia, capsular laxity, and degeneration. Patients with labral tear complain about anterior hip or groin pain most commonly with a most consistent physical examination called positive anterior hip impingement test. Magnetic resonance arthrography is a reliable radiographic examination with arthroscopy being the gold standard. Conservative treatment consists of rest, non-steroidal anti-inflammatory medication, pain medications, modification of activities, physical therapy, and intra-articular injection.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right hip arthroscopy with labral surgery. Regarding the diagnosis and treatment of labral tear, researchers report, “Labral tear is generally secondary to femoroacetabular impingement, trauma, dysplasia, capsular laxity, and degeneration. Patients with labral tear complain about anterior hip or groin pain most commonly with a most consistent physical examination called positive anterior hip impingement test. Magnetic resonance arthrography is a reliable radiographic examination with arthroscopy being the gold standard. Conservative treatment consists of rest, non-steroidal anti-inflammatory medication, pain medications, modification of activities, physical therapy, and intra-articular injection.
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 labral tear 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.