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Medical Condition: when insurers say no, reviewers often say yes
In 156 published external-review decisions involving medical condition, independent physician reviewers overturned the insurer’s denial 78.8% of the time.
Published decisions
156
2001–2026
Overturned
78.8%
123 denials reversed
Most-fought treatments for medical condition
What insurers denied — and how those fights ended.
| Treatment | Decisions | Overturned |
|---|---|---|
| Breast Tomosynthesis | 80 | 96.2% |
| Digital Breast Tomosynthesis | 24 | 95.8% |
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for medical condition was denied, the published record says the denial is worth fighting.
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.