Appeal win rates · California
Dental and orthodontic care: 55% of denials overturned
Only 23 decisions since 2021, so this page leads with all years since 2001. Across all years since 2001: 55% of 168.
Year by year
Show as a table
| Year | Decisions | Overturned |
|---|---|---|
| 2005 | 11 | 36% |
| 2006 | 7 | 57% |
| 2009 | 6 | 50% |
| 2010 | 9 | 22% |
| 2012 | 5 | 80% |
| 2013 | 5 | 20% |
| 2014 | 5 | 60% |
| 2015 | 8 | 50% |
| 2016 | 19 | 58% |
| 2017 | 27 | 59% |
| 2018 | 9 | 44% |
| 2019 | 12 | 50% |
| 2020 | 7 | 57% |
| 2021 | 8 | 50% |
| 2024 | 7 | 71% |
By treatment
| Treatment | All years | Since 2021 |
|---|---|---|
| Dental anesthesia | 58% of 36 | 4 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.
Overturned Dental implants · Teeth Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the surgical placement of an implant body, endosteal implant of tooth #3. Signs and symptoms of dental implant failure include one or more of the following: horizontal…
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the surgical placement of an implant body, endosteal implant of tooth #3. Signs and symptoms of dental implant failure include one or more of the following: horizontal mobility greater than 0.5 mm, rapid progressive bone loss, pain during percussion, uncontrolled exudate, generalized radiolucency around the implant, loss of more than half of the bone around the implant, and, lastly, the implant(s) become inserted into poor position(s), making the implant useless for prosthetic support. Following the removal of the prior implant due to chronic infection and bone loss, the subsequent debridement and bone grafting were performed in accordance with dental implantation standards. This process was followed by an implant placement to restore dental functionality, prevent occlusion shifting, avoid alveolar bone loss, and restore masticatory function, all of which are key points in preventing nutritional deficiency, which ultimately affects the general health of the patient. All told, the surgical placement of an implant body, endosteal implant of tooth #3, was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service provided 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 oral, facial, and maxillary 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 MN25-44495
Upheld Other · Bones, joints and muscles The physician reviewer found that the patient has requested authorization and coverage for Invisalign treatment. While some anecdotal cases may suggest that Invisalign treatment may fix alignment and harmonize the bite to improve temporomandibular joint (TMJ)…
The physician reviewer found that the patient has requested authorization and coverage for Invisalign treatment. While some anecdotal cases may suggest that Invisalign treatment may fix alignment and harmonize the bite to improve temporomandibular joint (TMJ) symptoms, current medical literature does not support orthodontics, specifically clear aligners, as a treatment for TMJ. There is a lack of data showing that Invisalign treatment is appropriate to treat TMJ pain or its symptoms. Studies suggest that TMJ and orthodontic treatments should be treated separately. Researchers explain that orthodontic treatment may affect occlusion, bite force, and jaw movement, which may cause or worsen temporomandibular disorder (TMD) symptoms. Researchers report that orthodontists often have trouble treating patients with TMJ disorders because occlusion changes depend on the position of unstable condyles. In this case, while a Handicapping Labio-Lingual Deviation (HLD) index score sheet reported a total score of 27, clinical photographs of the patient did not support this scoring. In this clinical setting, given the lack of support in current medical literature regarding the use of Invisalign treatment for the treatment of TMD and associated migraines, the requested service is not medically indicated. Therefore, Invisalign treatment is 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 licensed D.D.S, board certified in dentistry, 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 MN24-42634
Upheld Other · Teeth The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the veneer for tooth 8. In this case, the patient presented to her provider with a chipped tooth and was provided with treatment options…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the veneer for tooth 8. In this case, the patient presented to her provider with a chipped tooth and was provided with treatment options, including a two-surface composite filling or veneers. In this clinical setting, the treatment option for veneers is a purely cosmetic election, as a mesiolingual (ML) composite filling would be sufficient to treat the minor piece of chipped enamel that the patient reported. Such a minor piece of chipped enamel would not affect the patient’s ability to chew, and the records did not indicate that the patient reported pain. The patient elected to proceed with veneers. While notes reported that veneers were cemented with Fuji cement, veneers are generally bonded. The bonding of veneers with a resin luting agent requires the etching of the porcelain, etching the tooth, applying primer to the tooth, and air drying, followed by application of the bond to the tooth, air thinning, and light curing. The patient reported that the veneers were popping off. The records noted that the veneers were not broken, and photographs submitted on behalf of the patient showed that the veneer on tooth #8 was securely in place. In this clinical setting, given that a two-surface composite ML filling would have been sufficient to treat the patient’s chipped tooth, the service at issue was not medically indicated. Therefore, the veneer for tooth 8 was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was 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.D.S, board certified in dentistry, 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 MN24-42243
Overturned Orthodontia/ braces · Teeth Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for complete adolescent orthodontia treatment for 25 months. The American Association of Orthodontics defined medically necessary orthodontic care as…
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for complete adolescent orthodontia treatment for 25 months. The American Association of Orthodontics defined medically necessary orthodontic care as requiring an auto-qualifier out of a list that includes specific conditions. With regard to this patient, one of these conditions has been met, specifically the auto-qualifier of impinging overbite with evidence of occlusal contact into the opposing soft tissue. The patient’s photographs and cephalometric X-rays demonstrate that a deep bite is visible. In addition, the photographs support that the patient’s impinging deep overbite is causing soft tissue laceration of the palate. Therefore, the requested complete adolescent orthodontia treatment for 25 months is 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 a licensed D.D.S, board certified in orthodontics with subspecialty certification in pediatric dentistry, 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 MN24-41846
Overturned Other · Teeth Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgically assisted maxillary expansion. The records indicate that this patient presents with a history of class 1 relationship with a skeletal open bite…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgically assisted maxillary expansion. The records indicate that this patient presents with a history of class 1 relationship with a skeletal open bite pattern, skeletal maxillary constriction with a bilateral crossbite, only posterior teeth touching while biting down, and maxillary and mandibular crowding. The patient’s provider has recommended treatment with surgically assisted maxillary expansion. The medical literature supports an indication for maxillary expansion of the narrow maxilla in this patient’s case. One study noted that “The surgical-assisted rapid maxillary expansion has gradually become popular to correct transverse maxillary hypoplasia.” On review of the available documentation, the patient reports difficulty chewing food properly and an inability to bite with his anterior teeth. The patient’s problems, including a narrow maxilla, can cause systemic medical complications such as obesity and diabetes, obstructive sleep apnea and airway diseases, temporomandibular joint disorders, narrowing of the pharyngeal dimension, chronic headaches, and speech and hearing issues. Therefore, the requested surgically assisted maxillary expansion is medically necessary for the treatment of this patient. 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. The reviewer is board-certified in oral facial and maxillary 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 MN24-41633
Overturned Other · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a subacromial decompression provided as part of an authorized right shoulder arthroscopic surgical procedure. According to one study, “Following nonoperative treatment for at…
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a subacromial decompression provided as part of an authorized right shoulder arthroscopic surgical procedure. According to one study, “Following nonoperative treatment for at least 6 weeks, subacromial decompression (SAD) is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff. Care should be taken to avoid resection of the acromioclavicular ligament. Five millimeters of lateral acromion resection is the recommended amount of resection.” Similarly, another study supports surgical treatment for refractory shoulder impingement cases, and includes decompression, debridement, and/or repair of injured structures. In this case, the patient was noted to have an intact rotator cuff, with diagnostic imaging studies corroborating significant degenerative changes of the acromioclavicular joint. The patient had tried and failed conservative treatment modalities including physical therapy, chiropractic treatment, subacromial bursa injection, acromioclavicular joint injection, and medications. Overall, due to the severity of the clinical and imaging-documented pathology, as well as the patient’s failed conservative treatment modalities, the subacromial decompression provided as part of the authorized right shoulder arthroscopic surgical procedure was medically necessary for the treatment of the patient. Final Result: The reviewer determined that the procedure 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 orthopedic surgery 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 MN24-41321
Overturned Dental implants · Teeth Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for general anesthesia services. Researchers report that implant surgery is a lengthy dental procedure, and that the most important goal with sedation is to ensure that the…
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for general anesthesia services. Researchers report that implant surgery is a lengthy dental procedure, and that the most important goal with sedation is to ensure that the surgery is performed safely and as planned. A researcher notes that pharmacologically, patients with dental anxiety may be managed using either sedation or general anesthesia. The authors further note that decisions regarding sedation or general anesthesia in cases of extreme anxiety may be made on a case-by-case basis between the patient and the treating surgeon. In this case, the treating oral surgeon noted that the patient’s anxiety regarding the procedure made her unwilling to tolerate the procedure with lesser sedation. This indicates that the provider, based on clinical judgement, was unwilling to risk the patient’s safety using local anesthesia, or any other type of lesser sedation, to complete the implant procedures. In this clinical setting, given that current medical literature supports the patient’s oral surgeon determination deeming general anesthesia necessary for the patient’s safety to complete the procedure, the services at issue were medically indicated. Therefore, general anesthesia services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is licensed D.D.S, board certified in dentistry, 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 MN24-41273
Overturned Other · Teeth The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for periodontal scaling and root planning. The patient has radiographic calculus on the lower right quadrant, as well as bone loss…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for periodontal scaling and root planning. The patient has radiographic calculus on the lower right quadrant, as well as bone loss on the upper right quadrant, lower right quadrant, and upper left quadrant. Based on the radiographs and the documented clinical condition of the patient, periodontal scaling and root planning is indicated to treat the patient. Periodontal disease is a chronic, complex, and infectious condition that affects the periodontium. Its progressive form can be identified by the loss and destruction of the periodontal ligament and the alveolar bone, respectively. Periodontal disease, one of the most prevalent oral cavity diseases, is responsible for tooth loss. Scaling and root planning is a recommended, non-invasive periodontal therapy for treating patients with periodontitis. Given these findings, the requested periodontal scaling and root planning is medically necessary for the treatment of the patient. Final Result: The reviewer determined that the requested procedure is 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 dentist 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 MN24-40703
Upheld Bridges · Teeth The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency services or urgently needed medical services. On review of the available documentation, the services were not emergency services…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency services or urgently needed medical services. On review of the available documentation, the services were not emergency services or urgently needed medical services as defined by California law. Per the records, the patient’s treatment rendered was due to oral pain arising from teeth numbers 28 and 31, which were endodontically treated by the provider to relieve the pain. The provider charted that they performed endodontic treatment on teeth numbers 31 and 28 to relieve the patient’s pain. The patient then received a crown build-up and a bridge. Although root canal services were covered by the Health Plan for the provision of emergency services, anything additional was not considered for the treatment of an emergent or urgent condition. Specifically, the patient could have been scheduled to undergo crown build-up and placement of a bridge at a later date, since these services were not emergent or urgent, and could have been delayed until the patient returned to the Health Plan’s service area. The services were not medically necessary to determine if an emergency medical condition or active labor existed or to relieve or eliminate an emergent medical condition. Moreover, the services were not medically necessary to prevent serious deterioration of the health of the patient, resulting from an unforeseen illness, injury, or complication of an existing condition, for which treatment could not have been delayed until the patient returned to the Health Plan’s service area. Therefore, the services were not emergency services or urgently needed medical services as defined by California law. Final Result: The reviewer determined that the services were not emergency services as defined by California law. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral, facial, and maxillary 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 UR23-40599
Upheld Dental implants · Teeth Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for implant placement for tooth number 25. Findings: The physician reviewer found that the records indicate that the patient failed endodontic treatment of tooth number 25…
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for implant placement for tooth number 25. Findings: The physician reviewer found that the records indicate that the patient failed endodontic treatment of tooth number 25 which was extracted and a dental implant was placed over the course of nine months. As noted in the medical literature, a single-tooth implant is one means of dental restoration, but it is not the only treatment option. A single-tooth implant may be indicated for patients due to cancer resection or skeletal deformity. However, this patient’s records do not document that the dental implant on tooth number 25 was performed due to cancer resection or skeletal deformity. Currently, there are various dental restoration options including a partial denture and a bridge, which would have been appropriate in this patient’s clinical setting. One study noted that their study comparing satisfaction between patients treated with a single-tooth implant or resin-bonded bridge for single missing tooth replacement demonstrated similarly high levels of satisfaction. This patient’s records indicate that she was a candidate for treatment with a resin-bonded bridge. For these reasons, the implant placement for tooth number 25 was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 oral, facial, and maxillary 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 MN23-39215
Upheld Dental anesthesia · Teeth Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dental anesthesia for teeth extractions in the hospital setting. Medical literatures explain, “In 1974, the American Dental Association first considered…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dental anesthesia for teeth extractions in the hospital setting. Medical literatures explain, “In 1974, the American Dental Association first considered recommending that dental offices measure blood pressure (BP) routinely, and it has been further encouraged since 2006. Investigators in several dental publications have recommended cancellation of dental procedures based solely on BP greater than 180/110 millimeters of mercury for urgent oral health care and greater than 160/100 mm Hg for elective oral health care, in the absence of prior medical consultation.” In this case, notes reported a blood pressure reading of 178/89 mm Hg. In this clinical setting, a pre-operative blood pressure reading will determine how to proceed with dental care and outpatient dental care recommendations. In cases of emergency dental care, the protocol is to retake the blood pressure, and to proceed if the second reading is lower or no higher than 180/109 mm Hg, or to monitor every 15 to 20 minutes if the secondary reading remains high but not above 180/109 mm Hg, as pain may be a contributing factor. If a blood pressure consistently reads greater than 180/109 mm Hg, the patient would need to seek medical consultation immediately, and no dental treatment should be rendered. With blood pressure readings between 160/100mm Hg to 180/109 mm Hg, a post-operative blood pressure reading is recommended to determine if a medical consultation may be needed. Therefore, based on these criteria, dental anesthesia for teeth extractions in the hospital setting is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is 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.D.S, board certified in dentistry, 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 MN22-38149
Upheld Orthodontia/ braces · Teeth The physician reviewer found that The patient’s parent has requested authorization and coverage for braces. Based on the available documentation, the provider’s submitted HLD score of 26 noted by the provider was overcalculated. The major discrepancy in the…
The physician reviewer found that The patient’s parent has requested authorization and coverage for braces. Based on the available documentation, the provider’s submitted HLD score of 26 noted by the provider was overcalculated. The major discrepancy in the submitted HLD score and the records is in the scoring of the anterior-posterior (AP) spread. The provider submitted an 8 mm AP spread, which is not supported by the photographs provided for review, which supports an AP spread of 4 mm. Based on the records, the HLD index review included an overjet of 4 mm, overbite of 3 mm, anterior crowding for 5 points on the upper and 5 points on the lower, and an AP spread of 4 mm, for an HLD index score of 21. The records support a score of 21 on the HLD, which is below the required threshold to support a medical indication for the requested braces and associated orthodontic services. As with any malocclusion, orthodontic correction would aid in the patient’s ability to chew and tear food and aesthetics, so the requested treatment would benefit the patient functionally. However, there is a lack of evidence of a health condition caused by the current occlusion to support that the requested procedure is necessary for the patient to achieve adequate nutrition. The patient’s mother states that the patient bites cheek, has a lisp due to malocclusion, and has very crowded teeth. Overall, the records do not demonstrate that the patient has any significant health issues related to the requested orthodontic services to support the requested treatment with a HLD score below the threshold recommended for the requested orthodontic services. All told, the requested braces are not necessary to prevent disease and promote oral health, or restore oral structures to health and function. Final Result: The reviewer determined that the requested services are not necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld.
Case MN22-37174
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).