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Anti-inflammatories denials: what the review data shows
Independent reviewers have decided 266 published cases where an insurer denied Anti-inflammatories — and they overturned the insurer 52.6% of the time. A denial for Anti-inflammatories is a starting position, not a final answer.
Published decisions
266
2001–2026
Overturned
52.6%
140 denials reversed
Conditions behind anti-inflammatories denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Osteoarthritis | 29 | 37.9% |
| Psoriasis | 21 | 47.6% |
| Crohns Disease | 15 | 66.7% |
| Ulcerative Colitis | 11 | 81.8% |
| Back Pain | 9 | 33.3% |
| Arthritis | 8 | 37.5% |
| Rheumatoid Arthritis | 8 | 12.5% |
| Crohn's Disease | 7 | 71.4% |
| Autoimmune Disease | 7 | 57.1% |
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. | 245 | 53.5% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 21 | 42.9% |
Typical time to a decision
13 days
Most land between 5 and 21 days
Handled as urgent
38%
Expedited when a delay would cause harm
Recent direction
Rising
57.1% → 72.1% 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: An enrollee has requested authorization and coverage for rituximab-pvvr, biosimilar, (Ruxience) 1,000 mg. In this case, the patient's history appears most consistent with interstitial pneumonia with autoimmune features (IPAF). She has responded well to steroid therapy and demonstrated clinical improvement with a trial with Rituxan. In this clinical setting, while it appears that the patient may respond well to Rituximab therapy, most studies on using Rituximab are regarding connective tissues disease associated interstitial lung disease (CT-ILD). Few trials evaluate its use in the IPAF group. In CT-ILD, it has been demonstrated to be effective in both acute exacerbations as well as in chronic management to prevent decline.
Findings: The physician reviewer found that The patient’s parent has requested authorization and coverage for Emflaza 30 mg tablets. The American Academy of Neurology guideline on corticosteroid treatment of Duchenne muscular dystrophy (DMD) reports, “Prednisone 0.75 mg/kg/d has significant benefit in DMD management and should be considered the optimal prednisone dose. Prednisone 10 mg/kg/weekend is equally effective over a 12-month period, although long-term outcomes of this alternate regimen remain to be seen.” While the U.S. Food and Drug Administration (FDA) does not specifically approve the use of prednisone for the treatment of DMD, it approves the use of deflazacort (Emflaza) for the treatment of DMD in patients age five and older.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician 1The patient is a 69-year-old woman who has followed a typical course for Takayasu’s arteritis and has stenosis of the left subclavian artery, carotid arteries, right vertebral artery, left ulnar artery, and branches of the aorta supplying the kidneys. She has had numerous bypass surgeries to maintain blood flow to her upper extremities and stenting of her renal arteries. In September 2003, studies revealed 70% stenosis of her celiac axis and superior mesenteric artery. The patient’s disease continues to be very aggressive despite prednisone treatment and Plaquenil. The patient’s provider has recommended Enbrel. The Health Plan has denied authorization for Enbrel on the basis that it is considered investigational for treatment of Takayasu’s arteritis.The pathogenesis of Takayasu’s arteritis and temporal arteritis are very similar.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel.Findings: The physician reviewer found that American College of Rheumatology guideline on the treatment of psoriatic arthritis notes, “In treatment-naive patients with active psoriatic arthritis (PsA), a tumor necrosis factor inhibitor (TNFi) biologic agent is recommended over an oral small molecule (OSM) as a first-line option. OSMs may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis, those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease.
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 Anti-inflammatorieswhen 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.