Hip Replacement denials: 32.7% overturned by independent reviewers
In 107 California IMR decisions from 2001 to 2025, reviewers overturned the plan 35 times (32.7%). In the last five years: 12.5% of 24. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Orth/Musculoskeletal | 100 | 30.0% | 9.1% of 22 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 33.3% |
| 2022 | 6 | 16.7% |
| 2023 | 2 | 0.0% |
| 2024 | 7 | 0.0% |
| 2025 | 6 | 16.7% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 35 | 28.6% | 32.7% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 23 | 21.7% | 32.7% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 15 | 53.3% | 32.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 14 | 7.1% | 32.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 11 | 36.4% | 32.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 9 | 11.1% | 32.7% |
| Urgent or emergencyThe findings mention urgency. | 6 | 16.7% | 32.7% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 66.7% | 32.7% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for total left hip replacement, anterior approach. Total hip arthroplasty is an established and effective treatment for relieving joint pain and disability and is a procedure of choice for end-stage degenerative joint disease. Surgery is indicated for osteoarthritis patients who have not responded …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral total hip arthroplasty. Current medical literature supports the use of hip arthroplasty in obese and even morbidly obese patients. In a study including 295 total knee replacements and 195 total hip replacements, Sharrock and colleagues found that an increased body mass index (BMI) is not associated …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hip surgery arthroscopy hip with femoroplasty and arthroscopy hip with labral repair. Findings: The physician reviewer found that Hip arthroscopy appears to be a safe and efficacious treatment for labral tears and femoroacetabular impingement (FAI) in older patients who do not have significant underlying degenerative changes. However, …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Hip Replacement denials overturned?
In 107 California IMR decisions from 2001 to 2025, reviewers overturned the plan 35 times (32.7%). In the last five years: 12.5% of 24.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.