Steroid Injection for Orth/Musculoskeletal: 66.7% of denials overturned
In 81 California IMR decisions from 2001 to 2025, reviewers overturned 54 (66.7%). In the last five years: 74.4% of 39. 70 were medical-necessity disputes, 11 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 7 | 85.7% |
| 2022 | 8 | 37.5% |
| 2023 | 5 | 80.0% |
| 2024 | 11 | 81.8% |
| 2025 | 8 | 87.5% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 31 | 61.3% | 66.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 12 | 83.3% | 66.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 8 | 50.0% | 66.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 12.5% | 66.7% |
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 a series of Euflexxa injections to the right knee. Viscosupplementation is generally considered in patients with osteoarthritis who have had prior benefit from injections and have limited remaining treatment options after failure of conservative measures. In this case, the patient has documented …”
“The physician reviewer found that an enrollee has requested authorization and coverage for bilateral sacroiliac joint injections at L5/S1. The enrollee recently presented with worsening bilateral lower‑extremity pain radiating into the buttocks. The record indicates that the enrollee has been treated with medications, physical therapy, chiropractic care, massage, acupuncture, and heat with limited relief.The enrollee has also received prior steroid …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for therapeutic bilateral sacroiliac joint injections with fluoroscopy. According to expert guidelines, fluoroscopic-guided corticosteroid joint injections are recommended for persistent sacroiliac joint pain that has persisted despite conservative measures. In a study, patients who received sacroiliac joint injections reported lower pain scores following …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for facet injections. Per the medical records, while magnetic resonance imaging (MRI) of the lumbar spine demonstrated mild facet osteoarthritic changes at L4-L5, other plausible causes of the subjective pain complaints are also evident. In this clinical setting, given that the records do …”
- 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 Steroid Injection denials for Orth/Musculoskeletal overturned?
In 81 California IMR decisions from 2001 to 2025, reviewers overturned 54 (66.7%). In the last five years: 74.4% of 39. 70 were medical-necessity disputes, 11 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.