Jaw Surgery for Dental Problems: 100.0% of denials overturned
In 10 California IMR decisions from 2002 to 2025, reviewers overturned 10 (100.0%). In the last five years: 100.0% of 2. 10 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2025 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for orthognathic surgery. In this case, the records establish that the patient has maxillary hypoplasia and mandibular hyperplasia (prognathism), resulting in malocclusion and facial asymmetry. The patient reports difficulty biting and chewing, an uncomfortable bite, difficulty smiling, and issues with tongue positioning. Surgical …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for jaw surgery consisting of maxillary LeFort osteotomy with activation of a transverse distracter to widen the maxilla (CPT 21142). The records provided for review document that this patient presents with a history of transverse maxillary hypoplasia. The patient is status post multiple surgeries to advance his maxilla …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthognathic surgery consisting of: midface reconstruction, LeFort 1 maxillary osteotomy, three segments, with autogenous local graft-advancement with clockwise occlusal plane rotation ; mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid internal fixation-setback with counter clockwise occlusal plane rotation; and interocclusal surgical guide.At issue in …”
- 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 Jaw Surgery denials for Dental Problems overturned?
In 10 California IMR decisions from 2002 to 2025, reviewers overturned 10 (100.0%). In the last five years: 100.0% of 2. 10 were medical-necessity disputes.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
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 they weigh the same things.
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.