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Orthotics denials: what the review data shows
Independent reviewers have decided 133 published cases where an insurer denied Orthotics — and they overturned the insurer 69.2% of the time. A denial for Orthotics is a starting position, not a final answer.
Published decisions
133
2001–2026
Overturned
69.2%
92 denials reversed
Conditions behind orthotics denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Foot Toe Pain | 16 | 75% |
| Pes Planus Flat Feet | 9 | 66.7% |
| Pediatric Ortho | 5 | 100% |
| Joint Problem Pain | 4 | 100% |
| Bunion | 4 | 100% |
| Tendon Problem | 4 | 75% |
| Deformities | 4 | 50% |
| Osteoarthritis | 4 | 50% |
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. | 127 | 70.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 6 | 50% |
Typical time to a decision
15 days
Most land between 7 and 21 days
Handled as urgent
21.1%
Expedited when a delay would cause harm
Recent direction
Falling
82.1% → 71.4% 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
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for orthotics for the left and right foot provided on 12/12/22.The presentation of pes planovalgus deformity includes a decrease in the medial longitudinal arch with the rearfoot in valgus and the forefoot in abduction. Initially, the presentation may be asymptomatic but can progress to a significant source of pain in the heel, midfoot, calf, knee, lower back, and hip, and may result in increased deformity, loss of function, and abnormal gait. Treatment consists of both conservative and surgical management. Conservative treatment modalities include physical therapy or treatment with foot orthotics. Surgical treatment is used in those patients who failed conservative management and in those with fixed deformities.
Nature of Statutory Criteria/ Case Summary: This is a female that was seen by podiatry and diagnosed with posterior tibial tendonitis and pes planus (fallen arches) to both feet. The examination reports moderate loss of foot arch with a medical shift bilaterally and tenderness to the posterior tibial tendons bilaterally. She reports that her foot pain is relieved with rest and orthotics, and that her orthotics are broken down. Podiatry recommends new functional orthotics to control the potential collapse secondary to her pes valgus deformity. At issue is whether the custom molded orthopedic shoe inserts are medically necessary to treat the patient’s medical condition.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom myoelectric elbow-wrist-hand-finger orthosis (MyoPro 2 Motion G). There is a lack of evidence in current medical literature supporting the use of the requested device in assisting a patient with weakness of an upper limb due to a cerebral event, such as a brain tumor, in regaining neurological or muscular strength or function, such as the innate ability to use the arm for functional tasks when the orthosis is removed. The requested device takes time and effort to don and doff, with assistance from others, and is not proven to help a user become more independent. It is not proven to be well-adapted to everyday usage in the community setting, and there are high rates of abandonment due to its poor efficiency.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computerized knee ankle foot orthosis (HCPCS L2006).Findings: Two out of three physician reviewers found that a computerized knee ankle foot orthosis (HCPCS L2006) is not likely to be more beneficial for you than any available standard therapy.Deems-Dluhy and colleagues concluded, “The microprocessor swing and stance controlled knee-ankle-foot orthosis may contribute to improved quality of life and health status of patients with lower-extremity impairments by providing the ability to have better walking speed, endurance, and functional balance.” Pröbsting and colleagues concluded, “The microprocessor stance and swing control orthosis may facilitate an easier, more physiological, and safer execution of many activities of daily living compared to traditional leg orthosis technologies.” The…
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 Orthoticswhen 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.