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General Surgery denials: what the review data shows
Independent reviewers have decided 1,455 published cases where an insurer denied general surgery — and they overturned the insurer 48.3% of the time. If your denial is in this category, the odds say: appeal.
Published decisions
1,455
2001–2026
Overturned
48.3%
703 denials reversed
By denial reason
The excuse on the letter changes the odds — and the counter-strategy.
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 1,034 | 52.8% |
| experimental / investigational | 410 | 37.1% |
Within this category
Subcategories with at least 15 published decisions.
| Subcategory | Decisions | Overturned |
|---|---|---|
| Other | 434 | 38% |
| Gastric Bypass | 212 | 58.5% |
| Bariatric Other | 174 | 51.1% |
| Bariatric Lap Band | 126 | 44.4% |
| Bariatric Duod Swtch | 91 | 73.6% |
| Bariatric Surgery | 82 | 54.9% |
| GERD Procedure | 64 | 39.1% |
| Bariatric Roux-en-y | 63 | 73% |
| Breast Surgery | 62 | 40.3% |
| Revision Procedures | 40 | 30% |
| Hernia Repair | 36 | 44.4% |
| Circumcision | 23 | 34.8% |
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 category outcome when 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.