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OON Referral denials: what the review data shows
Independent reviewers have decided 183 published cases where an insurer denied OON Referral — and they overturned the insurer 27.3% of the time. A denial for OON Referral is a starting position, not a final answer.
Published decisions
183
2001–2026
Overturned
27.3%
50 denials reversed
Conditions behind oon referral denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Breast | 7 | 14.3% |
| ADHD | 4 | 75% |
| Osteoarthritis | 4 | 25% |
| Vertebral Disc Prob | 4 | 0% |
| Menorrhagia | 3 | 33.3% |
| Chronic Fatigue Synd | 3 | 33.3% |
| Knee Problem | 3 | 0% |
| Hearing Problem | 3 | 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. | 171 | 28.7% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 10 | 0% |
Typical time to a decision
16 days
Most land between 5 and 21 days
Handled as urgent
35.5%
Expedited when a delay would cause harm
Recent direction
Falling
52.9% → 25% overturned, last three years
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 bilateral breast implant removal, bilateral capsulectomy, bilateral breast reconstruction, and bilateral reinsertion of breast implants to be performed in one surgical procedure. Researchers state that traditionally, “capsular contracture is treated surgically, although it is important to note that treatment is only indicated in grades III and IV capsular contracture. The Baker classification describes four grades of capsular contracture, with grade I being a normal, soft breast; grade II being a minimally firm breast; grade III being a moderately firm breast with some visible deformity; and IV being a painful, hard, distorted breast. Grade III and IV contractures typically require surgical management.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for individual therapy services, two times a week. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services with a tertiary level of care physician who is dually board certified in both obstetrics and gynecology and reproductive endocrinology and infertility. Reproductive endocrinology and infertility medicine is a subspecialty of obstetrics and gynecology. As the name suggests, and according to the American Board of Obstetrics & Gynecology (ABOG), this subspecialty focuses on complex reproductive disorders. This may include the surgical management of these conditions. However, it should be noted that physicians in the field of general obstetrics and gynecology (OB/GYN) also manage a wide range of conditions on a routine basis.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services at a facility that specializes in obsessive compulsive disorder (OCD) and that provides exposure response prevention (ERP). Findings: The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement.
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 OON Referralwhen 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.