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Steroid Injection denials: what the review data shows
Independent reviewers have decided 86 published cases where an insurer denied Steroid Injection — and they overturned the insurer 66.3% of the time. A denial for Steroid Injection is a starting position, not a final answer.
Published decisions
86
2001–2026
Overturned
66.3%
57 denials reversed
Conditions behind steroid injection denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Back Pain | 22 | 68.2% |
| Osteoarthritis | 13 | 92.3% |
| Vertebral Disc Prob | 11 | 36.4% |
| Knee Problem | 10 | 80% |
| Knee Problem Pain | 4 | 50% |
| Joint Problem Pain | 3 | 66.7% |
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. | 75 | 70.7% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 11 | 36.4% |
Typical time to a decision
10 days
Most land between 3 and 20 days
Handled as urgent
54.7%
Expedited when a delay would cause harm
Recent direction
Rising
57.9% → 83.3% 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: An enrollee has requested authorization and coverage for facet injections and Percocet 10mg (60 per 30 days). The current medical evidence does not support facet injections in this clinical setting. A randomized control trial regarding the use of facet joint blocks concluded that facet blocks are not therapeutic (Cohen, S., et al.). The trial also concluded that higher responder rates in certain treatment groups suggested that facet blocks might provide prognostic value before radiofrequency ablation. American Society of Interventional Pain Physicians (ASIPP) guidelines for interventional techniques in chronic spinal pain stated that the evidence for therapeutic lumbar facet joint blocks is weak.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections for treatment of the enrollee’s knee pain. Findings: The physician reviewer found that nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities.
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 a Zilretta injection in the right knee. The records indicate that this patient is being treated for osteoarthritis of the right knee and pain in the right knee. The patient’s right knee pain was improved by nearly 100% with a Zilretta injection and lasted almost three months. The patient reported that the benefits of the Zilretta injection are gradually wearing off. She has noticed more burning pain over the medial aspect of her knee without radiation. Her pain is worse with prolonged walking and standing and better with sitting and rest. Physical examination of the right knee revealed a small effusion with a range of motion from 0-120 degrees with guarding and crepitus. The knee is unstable with 1+ laxity with valgus stress at 0, 30, and 90 degrees and the patellar grind is positive.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural steroid injections and facet joint injections. This patient presents with chronic low back pain radiating into the bilateral lower extremities in an L5-S1 dermatomal distribution with associated complaints of leg weakness. Signs and symptoms are generally consistent with neurogenic claudication and affect ambulatory tolerance. She has been diagnosed with lumbosacral radiculopathy. She has failed to adequately improve with long-term conservative treatment, including activity modification, medications, physical therapy, and home exercise. Her provider has recommended epidural steroid injections and facet joint injections.
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 Steroid Injectionwhen 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.