When denials get challenged, what actually happens?
California and New York publish every independent review decision they administer. We counted all of them — 104,633 decisions — because nobody should have to guess whether a denial is worth fighting.
independent review decisions counted
overturned in California (42,749 cases)
overturned in New York (61,884 cases)
Payers are losing more of the denials that get challenged
Two states, two different regulators, two different populations — and the same direction. In 2019, independent reviewers sided with the patient in 52.5% of California cases and 38% of New York cases. By 2026 that had risen to 69.6% and 53.6%.
The final year in each dataset is partial. Bar height is the overturn rate, not case volume.
Not all denials are equally worth fighting
Overturn rates vary enormously by what was denied. Some categories are reversed almost every time; others are upheld almost every time. Knowing which is which before you spend a staff afternoon on paperwork is the whole point.
California
Independent Medical Review · 2020 onward
| Treatment | Cases | Overturned |
|---|---|---|
| Weight Control | 1,531 | 87.3% |
| RTC | 1,389 | 80.6% |
| Viscosupp Injection | 656 | 97.9% |
| Biologics | 487 | 80.5% |
| Genetic/Genomic Test | 397 | 52.1% |
| Hormones | 357 | 51.5% |
| MRI | 339 | 54.6% |
| Skin Treatment | 313 | 79.9% |
| Diabetic Medication | 254 | 77.2% |
| Pain Medication | 225 | 36.9% |
| Digestion/GI Rx | 208 | 79.3% |
| Lab Work | 201 | 25.9% |
| IVIG Therapy | 189 | 60.8% |
| Proton Beam | 180 | 46.7% |
New York
External Appeals · 2019 onward
| Treatment | Cases | Overturned |
|---|---|---|
| Inpatient Hospital | 23,626 | 31.4% |
| Pharmacy/ Prescription Drugs | 11,621 | 52.2% |
| Home Health Care | 8,062 | 79.4% |
| Dental/ Orthodontic Procedure | 5,979 | 53.9% |
| Surgical Services | 3,415 | 50.7% |
| Pain Management | 1,471 | 45.6% |
| Durable Medical Equipment (DME) (including Wearable Defibrilllators) | 1,041 | 62.2% |
| Substance Abuse: Inpatient | 754 | 61.7% |
| Radiation Therapy | 540 | 54.3% |
| Skilled Nursing Facility | 487 | 35.7% |
| Mental Health: Inpatient | 444 | 59.7% |
| Diagnostic Testing (other than Radiology) | 404 | 46.5% |
| Genetic Testing | 394 | 37.1% |
| Advanced Imaging Services (Including PET/ MRI/ CT) | 385 | 49.6% |
| Physical Therapy | 362 | 42% |
| Radiology Services (including Ultrasound) | 322 | 58.7% |
How to read this — and how not to
These numbers are easy to misuse, so here is exactly what they do and do not say. We would rather you trust the smaller, accurate claim.
- These are EXTERNAL review decisions — the independent step that happens only after a health plan has already denied an internal appeal. That population is pre-filtered toward contestable denials, so these are not overturn rates for denials in general.
- California covers DMHC-regulated plans; New York covers fully-insured commercial, qualified health plans and Medicaid managed care. Neither includes self-funded employer (ERISA) plans or Medicare Advantage.
- The most recent year in each dataset is partial.
- Counts are whole-census aggregates, not samples or estimates.
Sources — check our work
Both are free, public, and downloadable by anyone. Our aggregation scripts are deterministic — the same query produces the same table every time.
We do this for your denials, not just for a chart.
Send us your ten worst denials. We’ll draft the appeals in 72 hours, free, and tell you honestly which ones history says are worth pursuing.