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Reconstructive & Plastic Surgery denials: what the review data shows
Independent reviewers have decided 1,310 published cases where an insurer denied reconstructive & plastic surgery — and they overturned the insurer 45.6% of the time. If your denial is in this category, the odds say: appeal.
Published decisions
1,310
2001–2026
Overturned
45.6%
598 denials reversed
By denial reason
The excuse on the letter changes the odds — and the counter-strategy.
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 1,261 | 45.2% |
| experimental / investigational | 47 | 59.6% |
Within this category
Subcategories with at least 15 published decisions.
| Subcategory | Decisions | Overturned |
|---|---|---|
| Other | 414 | 48.1% |
| Panniculectomy | 177 | 33.3% |
| Breast reduction | 165 | 56.4% |
| Liposuction | 87 | 39.1% |
| Breast Augmentation | 83 | 44.6% |
| Excess Skin Removal | 59 | 28.8% |
| Facial Feminization Surgery | 48 | 87.5% |
| Blepharoplasty | 45 | 31.1% |
| Implant Removal | 39 | 20.5% |
| Skin Resurfacing | 36 | 41.7% |
| Mastectomy | 34 | 73.5% |
| Mammoplasty | 28 | 53.6% |
| Hair Removal | 25 | 76% |
| Abdominoplasty | 17 | 29.4% |
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.