Ligament/Tendon Repair denials: 30.4% overturned by independent reviewers
In 23 California IMR decisions from 2019 to 2025, reviewers overturned the plan 7 times (30.4%). In the last five years: 25.0% of 16. 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 | 23 | 30.4% | 25.0% of 16 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 6 | 16.7% |
| 2022 | 4 | 25.0% |
| 2023 | 1 | 100.0% |
| 2024 | 3 | 0.0% |
| 2025 | 2 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 14 | 21.4% | 30.4% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 6 | 33.3% | 30.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 0.0% | 30.4% |
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
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for left knee surgery (knee arthroscopy with meniscus repair). In this case, the patient was being treated for a torn left meniscus. The patient presented with medial-sided left knee pain of acute onset. The records reflect that the patient had pain with twisting, turning, or flexing of the knee. The …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right biceps tenodesis as part of an approved right shoulder acromioplasty and rotator cuff repair surgical procedure. Findings: The physician reviewer found that Gottschalk and colleagues conducted a study to determine whether subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right shoulder surgery. The records provided for review document that this patient has a history of partial thickness rotator cuff tear, impingement syndrome, and arthritis of the acromioclavicular (AC) joint as noted on ultrasound. The provider reports that the patient has been treated with adequate conservative measures …”
- 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 Ligament/Tendon Repair denials overturned?
In 23 California IMR decisions from 2019 to 2025, reviewers overturned the plan 7 times (30.4%). In the last five years: 25.0% of 16.
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.