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Ligament Tendon Repair denials: what the review data shows
Independent reviewers have decided 23 published cases where an insurer denied Ligament Tendon Repair — and they overturned the insurer 30.4% of the time. A denial for Ligament Tendon Repair is a starting position, not a final answer.
Published decisions
23
2001–2026
Overturned
30.4%
7 denials reversed
Conditions behind ligament tendon repair denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Knee Problem Pain | 5 | 60% |
| Ligament Problem | 5 | 0% |
| Tendon Problem | 5 | 20% |
| Shoulder Problem Pain | 5 | 60% |
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. | 14 | 35.7% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 22.2% |
Typical time to a decision
10 days
Most land between 5 and 21 days
Handled as urgent
47.8%
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 reimbursement for platelet-rich plasma (PRP) injections for the right knee. This patient sustained a right knee injury and was diagnosed with a grade 3 medial collateral ligament (MCL) tear, anterior cruciate ligament (ACL) tear, medial meniscus tear, and lateral meniscus tear. She underwent ACL reconstruction with medial and lateral meniscus repair. Surgical augmentation with PRP was given as the MCL and meniscal capsular junction were not repaired surgically. A subsequent PRP injection was performed to the posterior lateral corner ligaments including popliteus, arcuate ligament, popliteal fibular ligament, and fibular collateral ligament.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right biceps tenodesis as part of an approved right shoulder acromioplasty and rotator cuff repair surgical procedure. Findings: The physician reviewer found that Gottschalk and colleagues conducted a study to determine whether subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV superior labral anterior and posterior (SLAP) lesions. They concluded that biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for any or all of the components of the requested left shoulder surgical procedure including arthroscopy, shoulder, surgical, with rotator cuff repair; tenodesis for rupture of long tendon of biceps; and/or arthroscopy, shoulder, surgical, debridement, extensive, three or more discrete structures. Researchers report, “In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for medial patellofemoral ligament (MPFL) reconstruction.Findings: The physician reviewer found that “MPFL reconstruction and medial patellofemoral soft-tissue surgery procedures were both effective in restoring the medial restraining forces preventing redislocation, but MPFL reconstruction provided better functional outcomes both at short-term and long-term follow-up. Thus, besides the treatment of predisposing factors, MPFL reconstruction seems to be, based on the results of this meta-analysis, a suitable strategy to restore the medial restraining function in the treatment of recurrent lateral patellar dislocation.” Hopper and colleagues explain, “The MPFL is the main restraining force against lateral patellar displacement. It is disrupted after patellar subluxation or dislocation.
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 Ligament Tendon Repairwhen 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.