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Denial reasons, decoded

Denial letters are written to end conversations. Each reason below has a meaning, a motive, and a counter-strategy.

How each reason holds up under review

Across 42,749 published external-review decisions, independent physicians overturned the insurer 52.5% of the time — but the odds move with the reason on the letter.

Medical Necessity
55.1%
overturned of 31,504 decisions. The most common reason, and the most winnable — these fights turn on your doctor's documentation.
Experimental/Investigational
45.3%
overturned of 10,476 decisions. Turns on published evidence. Appeals that cite studies and guidelines do the arguing.
Urgent Care
42.3%
overturned of 769 decisions. Expedited external reviews, decided in days. Fewer of them, and harder — but far from hopeless.

SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · CALIFORNIA DECISIONS · METHODOLOGY

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