Home / Treatments / Orthopedic Procedures
Orthopedic Procedures denials: what the review data shows
Independent reviewers have decided 1,676 published cases where an insurer denied orthopedic procedures — and they overturned the insurer 29.4% of the time. If your denial is in this category, the odds say: appeal.
Published decisions
1,676
2001–2026
Overturned
29.4%
493 denials reversed
By denial reason
The excuse on the letter changes the odds — and the counter-strategy.
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 876 | 35% |
| experimental / investigational | 782 | 22.9% |
Within this category
Subcategories with at least 15 published decisions.
| Subcategory | Decisions | Overturned |
|---|---|---|
| Other | 672 | 31.8% |
| Fusion | 244 | 27.9% |
| Artificial Disc Repl | 244 | 9.8% |
| Hip Replacement | 107 | 32.7% |
| Arthroscopy | 97 | 43.3% |
| Knee Replacement | 93 | 26.9% |
| Diskectomy | 46 | 17.4% |
| Fract/Bone Repair | 45 | 46.7% |
| Jaw Surgery | 40 | 77.5% |
| Laminectomy | 28 | 35.7% |
| Ligament/Tendon Repair | 23 | 30.4% |
| Charite | 21 | 0% |
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.