Ligament/Tendon Repair for Orth/Musculoskeletal: 30.4% of denials overturned
In 23 California IMR decisions from 2019 to 2025, reviewers overturned 7 (30.4%). In the last five years: 25.0% of 16. 14 were medical-necessity disputes, 9 experimental/investigational.
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 …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for external non-contracted right elbow ulnar collateral ligament reconstruction with allograft surgery. The records indicate that this patient was being treated for an ulnar collateral ligament tear. The patient underwent an ulnar collateral ligament reconstruction with allograft surgery. However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, …”
- 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 for Orth/Musculoskeletal overturned?
In 23 California IMR decisions from 2019 to 2025, reviewers overturned 7 (30.4%). In the last five years: 25.0% of 16. 14 were medical-necessity disputes, 9 experimental/investigational.
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.