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Viral Infection: when insurers say no, reviewers often say yes
In 33 published external-review decisions involving viral infection, independent physician reviewers overturned the insurer’s denial 39.4% of the time.
Published decisions
33
2001–2026
Overturned
39.4%
13 denials reversed
Most-fought treatments for viral infection
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Anti-virals | 9 | 33.3% |
| IVIG Therapy | 3 | 33.3% |
| Emergency Room | 3 | 66.7% |
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. | 25 | 40% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 20% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 3 | 66.7% |
Typical time to a decision
15 days
Most land between 6 and 21 days
Handled as urgent
45.5%
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 parent of an enrollee has requested authorization and coverage for genetic testing (cytogenomic SNP microarray). The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s congenital cytomegalovirus and developmental delay. At issue in this case is whether the requested genetic testing (cytogenomic SNP microarray) is medically necessary for treatment of the patient’s medical condition.Per researchers, the clinical utility of chromosomal microarray (CMA) is well established. CMA is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings: The physician reviewer found that acute respiratory syndrome coronavirus-2 (COVID-19) is a novel ribonucleic acid (RNA) coronavirus that is the etiologic agent responsible for the current pandemic. This virus typically causes flu-like symptoms, and can progress to severe acute respiratory failure, and multiorgan failure. There is currently no pharmacotherapeutic agent that is proven to be effective treatment for COVID-19 infection. Treatment is largely supportive, including managing symptoms, trying to prevent ventilatory failure, and preventing complications, as well as avoiding transmission to others.
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 reimbursement and prospective authorization and coverage for all or any long-term acute care hospital (LTACH) - intensive care unit (ICU) services. Barker-Davies and colleagues report that while long-term sequelae of COVID-19 are unknown, evidence from previous novel coronavirus outbreaks demonstrate impaired pulmonary and physical function, reduced quality of life, and emotional distress. The authors further report that rehabilitation of COVID-19 survivors requiring critical care who may develop psychological, physical and cognitive impairments should be tailored to individual patient needs. Barlow and colleagues note that there is currently no widely accepted standard of care in the pharmacologic management of patients with COVID-19.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage computed tomography (CT) scan to measure calcium in the coronary arteries. Primary prevention of arteriosclerotic cardiovascular disease requires attention to prevention and management of arteriosclerotic cardiovascular disease risk factors. Elevated serum cholesterol, usually defined by low-density lipoprotein (LDL) cholesterol, is a major arteriosclerotic cardiovascular disease risk factor. A patient’s 10-year arteriosclerotic cardiovascular disease risk should guide therapeutic considerations in patients ages 40 to 75. The higher the estimated arteriosclerotic cardiovascular disease risk, the more likely the patient will benefit from evidence-based statin treatment.
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 viral infection 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.