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Card Valve Repl denials: what the review data shows
Independent reviewers have decided 23 published cases where an insurer denied Card Valve Repl — and they overturned the insurer 73.9% of the time. A denial for Card Valve Repl is a starting position, not a final answer.
Published decisions
23
2001–2026
Overturned
73.9%
17 denials reversed
Conditions behind card valve repl denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Cardiac Valve Dis | 12 | 75% |
| Cardiac Heart Prob | 7 | 71.4% |
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. | 13 | 69.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 10 | 80% |
Typical time to a decision
7 days
Most land between 5 and 13 days
Handled as urgent
82.6%
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: An enrollee has requested authorization and coverage for a MitraClip procedure with a one-day hospital inpatient stay. The U.S. Food and Drug Administration (FDA) approves the use of percutaneous mitral valve repair using the MitraClip device for high-risk patients with degenerative or other primary mitral valve regurgitation. Asch and colleagues report that the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial demonstrated that patients with 3+ or 4+ mitral regurgitation who remained symptomatic despite maximally tolerated guideline directed medical therapy benefited from MitraClip implantation, regardless of their degree of left ventricle (LV) dysfunction, LV dilatation, pulmonary hypertension, severity of tricuspid regurgitation, or individual…
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter aortic valve replacement with prosthetic valve, percutaneous femoral artery approach.Findings: Two out of three physician reviewers found that the medical evidence supports the requested services in this clinical setting. The medical records demonstrate that the patient has symptomatic aortic stenosis, based on recent onset symptoms of dyspnea with limited (1 block or incline) exertion, fatigue and dizziness, and she therefore has Class II heart failure symptoms. The patient had a recent transthoracic echocardiogram (TTE) which revealed moderately severe to severe aortic stenosis secondary to a bicuspid valve.
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 authorization and coverage for transcatheter mitral valve replacement. There is a lack of formal guidelines or consensus statements available to support treatment with transcatheter mitral valve-in-valve replacement for treatment of this patient’s bioprosthetic mitral valve failure. Urena and colleagues noted that patients may be eligible for transcatheter mitral valve-in-valve replacement if “they are symptomatic, they are considered at high surgical risk, and their anatomy is suitable.” However, the available clinical trials comparing transcatheter mitral valve-in-valve replacement and surgical mitral valve replacement have not reported superior health outcomes with transcatheter approach. The U.S.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mitral valve repair (MitraClip). Findings: The physician reviewer found that U.S. Food and Drug Administration (FDA) approved percutaneous mitral valve repair using the MitraClip device for high risk patients with degenerative or other primary mitral valve regurgitation. The COAPT trial evaluated patients with 3-4+ mitral regurgitation who remained symptomatic despite maximally tolerated guideline directed medical therapy (Asch, et al.). The authors found that the patients benefited from MitraClip implantation, regardless of their degree of left ventricle (LV) dysfunction, LV dilatation, pulmonary hypertension or individual mitral regurgitation characteristics.
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 Card Valve Replwhen 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.