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Admission denials: what the review data shows
Independent reviewers have decided 211 published cases where an insurer denied Admission — and they overturned the insurer 51.7% of the time. A denial for Admission is a starting position, not a final answer.
Published decisions
211
2001–2026
Overturned
51.7%
109 denials reversed
Conditions behind admission denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Brain Injury Concussion | 7 | 85.7% |
| Stroke CVA | 7 | 14.3% |
| Auto Accident | 7 | 42.9% |
| Depression | 6 | 83.3% |
| Pneumonia | 5 | 80% |
| Chest Pain | 5 | 20% |
| Back Pain | 5 | 40% |
| Hernia | 4 | 50% |
| Bacterial Infection | 4 | 50% |
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. | 200 | 50.5% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 8 | 100% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 0% |
Typical time to a decision
18 days
Most land between 9 and 21 days
Handled as urgent
24.6%
Expedited when a delay would cause harm
Recent direction
Rising
66% → 71.8% overturned, last three years
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 reimbursement for mental health inpatient level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. For dimension 1, with regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for the full inpatient hospital stay. Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given when signs and symptoms include viral upper respiratory prodrome followed by increased respiratory effort, wheezing, and diffuse bilateral crackles, generally affecting infants less than 24 months of age. The most common causative agent is respiratory syncytial virus, but other viruses may also cause bronchiolitis, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient is a 60-year-old female with a history of chronic obstructive pulmonary disease (COPD), lung cancer, chronic kidney disease, and chronic liver failure who presented to the hospital for upper gastrointestinal bleeding, sepsis with hypoxemic respiratory failure from pneumonia and possible congestive heart failure with severe lactic acidosis. The patient was initially hospitalized in the intensive care unit (ICU) and was intubated and sedated. She was treated with intravenous (IV) antibiotics and was also noted to have worsening renal failure initially requiring continuous renal replacement therapy (CRRT) then hemodialysis (HD). She was also treated for clostridium difficile infection.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization and coverage for acute rehabilitation services provided from 10/17/18 forward. Per Gajofatto and colleagues, primary progressive multiple sclerosis is characterized by continuous disability worsening from the onset, with no disease-modifying therapy currently proven to favorably impact its course and outcomes. Beer and colleagues note that the mainstays of treatment include managing symptoms and maximizing function through rehabilitation interventions, including energy conservation and compensatory measures. Intensive and aggressive exercise are frequently not tolerated and can be counterproductive.In the present case, the enrollee is reported to have primary progressive multiple sclerosis.
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 treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Admissionwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
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.