Home / Treatments / Ongoing OON Tx
Ongoing OON Tx denials: what the review data shows
Independent reviewers have decided 57 published cases where an insurer denied Ongoing OON Tx — and they overturned the insurer 36.8% of the time. A denial for Ongoing OON Tx is a starting position, not a final answer.
Published decisions
57
2001–2026
Overturned
36.8%
21 denials reversed
Conditions behind ongoing oon tx denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Allergy | 8 | 0% |
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. | 41 | 48.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 14 | 7.1% |
Typical time to a decision
18 days
Most land between 6 and 22 days
Handled as urgent
38.6%
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: The patient has requested authorization and coverage for the insertion of a hepatic artery infusion pump. In a meta-analysis of the comparative effectiveness of hepatic artery based therapies for unresectable colorectal liver metastases, researchers conclude, “Hepatic arterial infusion, radioembolization, and transcatheter arterial chemoembolization are equally effective in patients with unresectable colorectal liver metastases with marginal differences in survival.” The National Comprehensive Cancer Network (NCCN) guidelines on the management of colon cancer note that clinical trials have shown a trend toward prolonged long-term survival with hepatic arterial infusion of chemotherapy, noting that hepatic artery infusion plus or minus systemic 5-FU/leucovorin is an option at institutions with experience in both surgical and medical oncologic asp…
The patient’s parent has requested authorization and coverage for hip to ankle scanogram/EOS imaging. The Health Plan denied the request and reported the requested services are not medically necessary for the evaluation of this patient. Researchers concluded that the “identification of congenital and acquired etiologies causing alignment disorders and leg-length discrepancies (LLD) in children is important for management.” Per the authors, “LLD of greater than 1 cm can cause altered biomechanics, resulting in scoliosis, back and lower extremity joint pain, pelvic tilt, abnormal gait and premature degenerative joint disease.” Medical literature states “upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services on the basis that the services were necessary for treatment of an emergency medical condition. The records show that the patient has a history of limbic encephalitis, muscle weakness, cognitive dysfunction, and was manifesting obsessive-compulsive disorder behaviors. The patient was brought to the emergency room on several occasions. The patient was admitted with four-point restraints due to severe aggressive outbursts, behavioral changes, altered level of consciousness, amnesia, schizophrenia, tic disorder, and a low suspicion of pediatric acute-onset neuropsychiatric syndrome (PANS). Seeking a second opinion, the patient and his family consulted several providers.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Shoemaker Protocol including office visit with qualified provider experienced with the Shoemaker Protocol once every four to six weeks until the Shoemaker Protocol is completed; Welchol 625 mg; liposomal vitamin C 500 mg; vasoactive intestinal peptide nasal spray; epinastine HCL 0.05% two drops twice daily; neuroquadrant magnetic resonance imaging (MRI) without contrast; macron biofilm analysis; nares culture; Singulair 10 mg once daily; Cromolyn 4 ampules twice daily; and cholestyramine non-saccharine 4 grams. CRIS is a controversial constellation of symptoms, which is not currently accepted as a diagnostic disorder.
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 Ongoing OON Txwhen 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.