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Thoracic Spine Pain: when insurers say no, reviewers often say yes
In 18 published external-review decisions involving thoracic spine pain, independent physician reviewers overturned the insurer’s denial 33.3% of the time.
Published decisions
18
2001–2026
Overturned
33.3%
6 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. | 15 | 33.3% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 33.3% |
Typical time to a decision
13 days
Most land between 5 and 21 days
Handled as urgent
55.6%
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: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the middle spine and/or right knee. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain, for an adult patient with initial radiographs demonstrating degenerative changes, an MRI may be appropriate as the next imaging examination, if the patient's symptoms are not explained by the radiographic findings. In this case, the patient’s pain persists despite conservative management and were not explained by radiographic findings. Therefore, an MRI is appropriate, and he may be a surgical candidate.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical/thoracic facet joint radiofrequency neurolysis. In this case, the patient presents with chronic thoracic spine pain which responded to two medial branch blocks, with 80% pain relief for six to eight hours, which is the expected duration of the joint blocks. Based on the patient’s response, there is level 3 evidence to support proceeding with radiofrequency ablation to treat the affected thoracic levels.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for thoracic facet joint injection and transforaminal lumbar epidural steroid injection. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s thoracic and lower back pain. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The current medical evidence does not recommend facet joint injections in the thoracic spine, as there is limited research on therapeutic blocks or neurotomies in this region. Per the medical evidence, therapeutic epidural steroid injections are recommended as a possible option for short-term treatment of radicular pain with use in conjunction with active rehabilitation efforts.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of thoracic spine without contrast material. CT scans are performed with high dose radiation and are not without risk. Findings: The physician reviewer found that A CT scan of the thoracic spine could expose the patient to up to 100 times the amount of radiation of an x-ray. CT of the thoracic spine may be indicated in cases with highly suspected thoracic spine pathology, calcified disc herniation with symptoms of myelopathy, suspected tumor, infection, or trauma, or assessment of spinal deformity and surgical planning. The patient does not meet these indications based on the submitted records. In this case, the submitted records do not show that the patient’s pain is of a long duration enough to suspect a more serious pathology.
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 thoracic spine pain 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.