Appeal win rates · California
Chiropractic care: 32% of denials overturned
Only 26 decisions since 2021, so this page leads with all years since 2001. Across all years since 2001: 32% of 158.
Year by year
Show as a table
| Year | Decisions | Overturned |
|---|---|---|
| 2003 | 7 | 57% |
| 2004 | 7 | 43% |
| 2005 | 8 | 38% |
| 2008 | 5 | 20% |
| 2009 | 12 | 17% |
| 2010 | 9 | 22% |
| 2011 | 8 | 25% |
| 2012 | 9 | 22% |
| 2013 | 8 | 13% |
| 2014 | 6 | 17% |
| 2015 | 9 | 33% |
| 2017 | 11 | 9% |
| 2018 | 11 | 36% |
| 2019 | 5 | 60% |
| 2020 | 5 | 60% |
| 2021 | 7 | 43% |
| 2023 | 7 | 43% |
| 2024 | 7 | 43% |
By treatment
| Treatment | All years | Since 2021 |
|---|---|---|
| Pain management | 35% of 37 | none |
| Spinal adjustment | 32% of 22 | 10 decisions |
Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.
Recent decisions
The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.
Upheld Spinal adjustment · Ear, nose and throat The physician reviewer found that a patient has requested authorization and coverage for chiropractic services. The enrollee reported prior chiropractic treatment, including neck traction, which they felt provided some symptom relief. One study noted that…
The physician reviewer found that a patient has requested authorization and coverage for chiropractic services. The enrollee reported prior chiropractic treatment, including neck traction, which they felt provided some symptom relief. One study noted that “Spinal manipulation inhibits back and neck pain partly through spinal segmental mechanisms and potentially through peripheral mechanisms regulating inflammatory responses. Other mechanisms remain to be clarified.” Another study commented that although support can be found for the use of thoracic manipulation for neck pain, function, and quality of life, results for cervical manipulation and mobilization versus control are few and diverse. Given these findings, the requested chiropractic services are not indicated for the management of this patient’s condition. Therefore, the requested chiropractic services are not medically necessary for the treatment of this patient’s dizziness. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in chiropractor and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-45413
Overturned Other · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrokinetic spinal decompression services. According to the medical literature, patients treated with aquatic therapy…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrokinetic spinal decompression services. According to the medical literature, patients treated with aquatic therapy experience improvements in pain, function, and quality of life. In this case, the patient has a history of back pain with multilevel disc bulge, cervical and lumbar compression with radiculitis, and a kyphotic posture. The patient’s pain has not been relieved by acupuncture or physical therapy. The use of aquatic-based exercise for the treatment of patients with similar clinical presentations is supported by the medical literature. All told, the requested hydrokinetic spinal decompression services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in chiropractor and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-44143
Overturned Spinal adjustment · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: The patient is a 51-year-old female requesting reimbursement for chiropractic services. The patient falls into multiple categories that would make the above rendered treatment medically appropriate in this clinical…
Nature of Statutory Criteria/Case Summary: The patient is a 51-year-old female requesting reimbursement for chiropractic services. The patient falls into multiple categories that would make the above rendered treatment medically appropriate in this clinical setting. A patient with chronic lower back pain can be seen and treated by a chiropractor around four times monthly. For exacerbations in their pain, patients can be seen two to three times per week for two to four weeks. Here, the patient has chronic lower back pain and spondylolisthesis. The number and frequency of visits in this case are in the acceptable range for the patient’s condition. Therefore, the requested chiropractic services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the treatment at issue was medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in chiropractor and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-43283
Overturned Spinal adjustment · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for chiropractic services. The Researchers recommend chiropractic spinal manipulation when specific criteria are met. These criteria include…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for chiropractic services. The Researchers recommend chiropractic spinal manipulation when specific criteria are met. These criteria include adequate documentation that the patient has symptomatic musculoskeletal or related disorder attributable to a mechanical, structural, or functional disorder of the sacroiliac, lumbosacral, lumbar, thoracic and/or cervical spine, or headache disorders. The criteria also require that there be an absence of contraindications to manipulation, mobilization, or diagnostic red flags suggesting a possible organic disorder in the treatment area. Per the guidelines, additional courses of care may be indicated if documentation shows that the patient has made clinically significant progress under the initial treatment plan based on a reliable and valid outcome tool or updated subjective and objective examination findings. In addition, clinically significant progress must be reasonably expected by continued treatment. In this case, the medical records indicate that the patient met the criteria set forth in the guidelines for chiropractic spinal manipulation. Thus, the initial chiropractic treatments received were medically necessary. However, the records do not show a change in objective findings and there is no documentation of a functional outcome assessment. As such, the additional chiropractic treatments provided are not supported as medically necessary due to a lack of clinical progress and functional improvements. Therefore, the chiropractic services initially provided were medically necessary, while the subsequent chiropractic services provided were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the chiropractic services were medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications: The reviewer is a licensed D.C., board-certified in chiropractic care, and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-41957
Upheld Spinal adjustment · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for treatment with a motorized decompression mechanical traction device.Lumbar disc herniation (LDH) is a clinical entity…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for treatment with a motorized decompression mechanical traction device.Lumbar disc herniation (LDH) is a clinical entity characterized by low back and leg pain caused by the compression of the lumbar spinal nerve root by a degenerative disc. The majority of patients respond to conservative treatment. Conservative treatment involves resting, drug therapy, physical therapy, exercise, manipulation, epidural injections, and bracing. One of the physical therapy modalities used in the treatment of LDH is traction. However, the authors of a study determined that medical literature suggests only short-term effectiveness of traction on low back pain with lumbar radiculopathy, regardless of the type employed. Further, despite the potential benefits of spinal traction treatment, clinical studies on existing traction therapy for lumbar disc disease patients are insufficient. All told, there are limited large-scale, long-term references showing the safety and efficacy of mechanical traction for the treatment of the lumbar spine. Further studies are needed to corroborate the clinical benefit of this treatment modality. Thus, the requested treatment with a motorized decompression mechanical traction device is not medically necessary for the treatment of the patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-41857
Upheld Evaluation · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic services. Researchers report, “Physical examination findings indicating hip dysfunction are common in patients…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic services. Researchers report, “Physical examination findings indicating hip dysfunction are common in patients presenting with lower back pain.” In a randomized controlled trial, researchers concluded, “Spinal manipulation improves the results of physiotherapy over a period of three months for patients with subacute or chronic lumbar radiculopathy.” In this case, the patient reports a dull tightness of the left hip that is not described as painful. The records do not document pain in the lower back. While chiropractic treatments may be appropriate if the patient’s hip dysfunction is due to low back pain, given that the patient’s reports of hip tightness are not accompanied by low back pain, the requested service is not medically indicated for the treatment of the patient’s tightness of the left hip. Therefore, chiropractic services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is a licensed D.C., L.Ac., board certified chiropractor, and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-41825
Overturned Joint manipulation · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for chiropractic services.According to Researches, scheduled interval ongoing management for secondary and tertiary prevention is recommended. The…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for chiropractic services.According to Researches, scheduled interval ongoing management for secondary and tertiary prevention is recommended. The guidelines indicate continued chiropractic treatments when the patient demonstrates clinical improvements and should be discharged from active care with self-care instruction once the patient is stable. In this case, a review of the records confirmed that the patient underwent chiropractic manipulation involving three to four regions, which included the thoracic spine and cervical spine. The record reveals that there were no symptoms reported in the cervical and thoracic regions, and no physical examination in the cervical and thoracic regions took place. Therefore, chiropractic services involving the patient’s cervical and thoracic spine were not medically necessary for the treatment of the patient. However, the patient demonstrated functional improvements with chiropractic treatments to the lumbar spine for the time period in question by hiking, running loops around the neighborhood, long car rides, standing, walking, and sitting. A review of the records establishes that the patient’s symptoms were manageable, and the patient was able to stand, walk, hike, and work with no discomfort at all when sitting. The records establish that the patient has experienced functional improvement to the lumbar spine with chiropractic services. Overall, the provider did report that the patient has made clinically significant progress to the lumbar spine under the treatment program during the time period in question. Therefore, the chiropractic services to the lumbar spine were medically necessary for the treatment of the patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications: The reviewer is a licensed D.C., board-certified chiropractor, and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-41542
Upheld Joint manipulation · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued chiropractic care. On review of the current medical records, the requested continuation of chiropractic care is not supported as medically necessary…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued chiropractic care. On review of the current medical records, the requested continuation of chiropractic care is not supported as medically necessary for the treatment of this patient’s cervical and lumbar spine pain. The Clinical Practice Guidelines for Chiropractors in the United States, support that there is a lack of documentation to support ongoing chiropractic services. The records do not establish that the patient has experienced functional improvement with chiropractic services. Overall, the provider did not report that the patient has made clinically significant progress under the initial treatment program based on reliable and valid outcome tools or updated subjective and objective examination findings. In addition, the current guidelines indicate that a patient’s records should document an absence of contraindications to manipulation, mobilization, or diagnostic red flags suggesting a possible organic disorder, which includes joint hypermobility or instability. The provider noted that this patient was diagnosed with chronic hypermobility syndromes, which is considered a contraindication for spinal manipulation therapy. Given these findings, the requested continued chiropractic care is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is licensed D.C., board-certified in chiropractic care, and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-41315
Upheld Spinal adjustment · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for chiropractic services. The records provided demonstrate that this patient underwent vertebral axial decompression on the dates of service at…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for chiropractic services. The records provided demonstrate that this patient underwent vertebral axial decompression on the dates of service at issue for the diagnosed condition of segmental dysfunction. There is a lack of high-quality, evidence-based data supporting that vertebral axial decompression is indicated for the treatment of segmental dysfunction. Rather, segmental dysfunction is typically treated with spinal manipulation. All told, the chiropractic services at issue were not likely to have been more beneficial for the treatment of the patient’s condition than any available standard therapy.Findings: Three of the three physician reviewers found that the services at issue were not likely to have been more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:Medical professional reviewer 1 is board certified in chiropractic care and is actively practicing. Medical professional reviewer 2 is board certified in chiropractic care and is actively practicing. Medical professional reviewer 3 is board certified in chiropractic care and is actively practicing. The reviewers are experts in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case EI24-43284
Overturned Other · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for additional chiropractic office visits and chiropractic therapy. In this case, the first ten chiropractic treatments were medically…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for additional chiropractic office visits and chiropractic therapy. In this case, the first ten chiropractic treatments were medically indicated. The patient was being treated for sacroiliac/lumbar/pelvic pain, which is within the scope of chiropractic treatment, and rated her pain at five out of ten, indicating some amount of pain. Regarding treatments following the first ten treatments, he records indicate that the patient rated her pain at a six out of ten on visit eleven and at a seven out of ten visit twelve. The records did not include a new orthopedic examination from visit eleven onward justifying continued chiropractic treatment. The documentation does not include comments from the provider on why the patient discontinued chiropractic treatment following visit ten. Therefore, the first ten additional chiropractic office visits and chiropractic therapy were medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications: The reviewer is a licensed D.C., board certified chiropractor, and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN23-40291
Upheld Other · Digestive system The physician reviewer found that The parent of a patient has requested authorization and coverage for chiropractic services. Despite a few limited case studies and some research into manual therapies for the treatment of patients with gastroesophageal reflux…
The physician reviewer found that The parent of a patient has requested authorization and coverage for chiropractic services. Despite a few limited case studies and some research into manual therapies for the treatment of patients with gastroesophageal reflux disease (GERD), there is a lack of established literature or evidence demonstrating that manual therapies have a positive effect on GERD symptoms. There is little mention of chiropractic manipulative management of GERD in the medical literature. Instead, the recommended treatment focuses on conservative management strategies such as lifestyle modification, mechanical interventions, and dietary strategies that can be provided by any medical professional. Therefore, chiropractic services are not medically necessary for the treatment of this patient. The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. The reviewer is board certified in chiropractic with subspecialty certification in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN23-40137
Overturned Spinal adjustment · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for chiropractic services.On review of the peer-reviewed medical literature, there is adequate support for the requested chiropractic spinal manipulation for the…
Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for chiropractic services.On review of the peer-reviewed medical literature, there is adequate support for the requested chiropractic spinal manipulation for the management of this patient’s back and sciatic nerve pain. In one study, the authors concluded that for well-selected patients with recurrent or persistent nonspecific low back pain who responded well to an initial course of chiropractic care, maintenance care should be considered an option for tertiary prevention. Another study revealed that spinal manipulation improved the results of physiotherapy over a period of three months for patients with subacute or chronic lumbar radiculopathy. A review of the record reflects that this patient has experienced low back and leg pain from sciatica for over 10 years. The patient reported a great deal of discomfort during employment and while performing activities of daily living. The record establishes that the patient has previously received successful chiropractic care for his low back pain. The patient underwent physical therapy without success. Overall, the current medical guidelines favor chiropractic care for low back pain and the patient has benefited from chiropractic care in the past. Therefore, the requested chiropractic services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board certified in chiropractic medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN23-39025
What these numbers mean
- These are decisions by independent doctors in California’s Independent Medical Review, run by the Department of Managed Health Care for the plans it regulates. They show how past denials ended, not the odds for any one case.
- “Overturned” means the reviewer sided with the patient and the plan had to cover the care. Only denials that reached independent review are counted.
- Plans in other states, and self-funded employer plans, use other independent reviewers; their results aren’t in this data.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, California Health and Human Services Open Data Portal, updated June 1, 2026. 42,749 decisions from 2001 to 2026 (2026 partial).