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Post-concussion Syndrome: when insurers say no, reviewers often say yes
In 15 published external-review decisions involving post-concussion syndrome, independent physician reviewers overturned the insurer’s denial 13.3% of the time.
Published decisions
15
2001–2026
Overturned
13.3%
2 denials reversed
Most-fought treatments for post-concussion syndrome
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| 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. | 10 | 20% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 0% |
Typical time to a decision
21 days
Most land between 20 and 21 days
Handled as urgent
13.3%
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 reimbursement for Intensive NeuroRestoration Program services, including hyperbaric oxygen therapy, therapeutic exercises, therapeutic activities, and manual therapy. In this clinical scenario, the patient was diagnosed with traumatic brain injury (TBI) and post-concussion syndrome. On review of the records, the patient’s presentation is consistent with post-concussion syndrome based on the history and physical findings including the Rivermead Post-Concussion Symptoms Questionnaire results. TBI can cause symptoms including headache, blurred vision, dizziness, as well as changes in consciousness, and problems with memory.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computerized dynamic posturography, quantitative electroencephalogram, Cambridge Brain Sciences Cognitive Test, and/or videonystagmography. Based on the available documentation, this patient presented to his provider with complaints of vertigo, headache, difficulty falling asleep and tiredness after sustaining head trauma from a water bottle. The patient underwent evaluation with computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain, which were interpreted as normal. The patient has symptoms suggestive of post-concussion syndrome. The use of the above the quantitative electroencephalogram and Cambridge Brain Sciences Cognitive Test would not alter the treatment of post-concussion syndrome.
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 outpatient vestibular (physical therapy) twice a week for eight weeks (CPT 97163 – physical therapy evaluation high complex; 97162 – physical therapy evaluation mod complex; 97110 – therapeutic exercises (including ROM, flexibility, endurance); 97112 – neuromuscular re-education)); and outpatient speech therapy (cognitive speech therapy) twice a week for six weeks (92522 – evaluation speech; 96125 – cognitive performance test; 97129 – therapy interventions/focus on cognition 30 minutes; 97130 – therapy interventions/focus on cognition additional 15 minutes).
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. Findings: The physician reviewer found that in this case has experienced chronic, persistent symptoms following remote head traumas. She has undergone vestibular rehabilitation without objective clinical benefit in the past and more recently with some subjective benefit reported. Based on the records provided for review, the patient has undergone sufficient rehabilitation to be independent with a home exercise and self-management program to further improve her balance, endurance, and activity tolerance. The provider noted that the patient is able to exercise on her own without difficulty, and she is participating in a yoga program focused on a history of brain injury.
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 post-concussion syndrome 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.