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Surgery denials: what the review data shows
Independent reviewers have decided 83 published cases where an insurer denied surgery — and they overturned the insurer 60.2% of the time. If your denial is in this category, the odds say: appeal.
Published decisions
83
2001–2026
Overturned
60.2%
50 denials reversed
By denial reason
The excuse on the letter changes the odds — and the counter-strategy.
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 60 | 63.3% |
| experimental / investigational | 22 | 54.5% |
Within this category
Subcategories with at least 15 published decisions.
| Subcategory | Decisions | Overturned |
|---|---|---|
| CNS Extracranial/Autonomic | 24 | 62.5% |
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.