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Braces denials: what the review data shows
Independent reviewers have decided 81 published cases where an insurer denied Braces — and they overturned the insurer 35.8% of the time. A denial for Braces is a starting position, not a final answer.
Published decisions
81
2001–2026
Overturned
35.8%
29 denials reversed
Conditions behind braces denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Knee Problem | 36 | 38.9% |
| Ligament Problem | 6 | 33.3% |
| Back Pain | 3 | 0% |
| Osteoarthritis | 3 | 0% |
| Scoliosis | 3 | 33.3% |
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. | 73 | 35.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 37.5% |
Typical time to a decision
21 days
Most land between 16 and 21 days
Handled as urgent
7.4%
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 patient has been diagnosed with adolescent idiopathic scoliosis of the thoracolumbar region. The documentation noted that she has been using a brace. The provider noted that the patient appeared to be realigning in the brace, and the expected outcomes would be achieved. The patient’s brace was noted to be too small, as she had grown four inches. Physical examination findings included an elevated shoulder height bilaterally, right scapular prominence, and waist asymmetry. The thoracic spine alignment was hypokyphotic, and the lumbar alignment was hypolordotic. Thoracic prominence (rib rotation) on the right was noted at eight degrees and lumbar paraspinal prominence was noted on the left at six degrees. The provider noted that a new brace was indicated.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for a Dynasplint device. Findings: The physician reviewer found that Furia and colleagues conducted a systematic review to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes. They concluded that dynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. John and colleagues conducted a randomized controlled trial to determine the efficacy of dynamic splinting in treating patients with postoperative hallux limitus. They concluded that dynamic splinting was effective in reducing contracture of postoperative hallux limitus.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for bilateral knee braces for treatment of the enrollee’s knee injury. Findings: The physician reviewer found that the evidence-based medical guidelines state that there are limited high quality studies that support or refute the benefits of knee braces for patellar instability, ACL tear, or medial collateral ligament instability. However, studies have found that in some patients a knee brace can increase confidence, which may indirectly help with the healing process. Pre-fabricated knee braces may be appropriate for patients with knee instability or ligament insufficiency/deficiency. Custom braces are supported when there is abnormal limb contour, such as disproportionate thigh and calf, precluding the use of a pre-fabricated brace.
Nature of Statutory Criteria/Case Summary: An enrollee has requested a right brace for treatment of her anterior cruciate ligament (ACL) injury. Findings: The physician reviewer found that the standard of care in the setting of therapy for anterior cruciate ligament (ACL) injuries is physiotherapy with a focus on recovery of strength, range of motion and agility. When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion restored. A neoprene sleeve can be used as an option for additional support. However, a functional ACL brace has not been proven in the medical literature to be an effective intervention for this condition.
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 Braceswhen 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.