Pain management: 79% of denials overturned

Year by year

By treatment

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.

1. Overturned 2026 · Medical necessity · age 41–50 Knee gel injections (viscosupplementation) · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Synvisc-One injection to both knees. Per the medical records, the patient has osteoarthritis in both knees, accompanied by…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Synvisc-One injection to both knees. Per the medical records, the patient has osteoarthritis in both knees, accompanied by chronic pain. The patient has tried and failed other conservative treatments. The patient has a history of relief from prior viscosupplementation. Given the patient’s limited options and based on the current medical literature, Synvisc-One injection to both knees 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 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 MN26-46505

2. Upheld 2026 · Medical necessity · age 41–50 Epidural injections · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an epidural steroid injection and/or selective nerve root block injection. Current clinical literature provides mixed evidence…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an epidural steroid injection and/or selective nerve root block injection. Current clinical literature provides mixed evidence regarding the long-term efficacy of epidural steroid injections for chronic low back pain with radicular symptoms. Some studies suggest only limited short-term benefit, without clinically meaningful or sustained improvement in pain or function.According to the medical records, the patient has low back pain with bilateral lower extremity pain and weakness. Available evidence indicates that while epidural steroid injections may provide temporary symptom relief in some patients, the overall benefit is generally modest and short term. Given these findings, the requested epidural steroid injection and/or selective nerve root block injection are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatments 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 physical medicine and rehabilitation with subspecialty certifications in pain medicine and brain injury medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46412

3. Overturned 2026 · Experimental or investigational · age 31–40 Nerve blocks · Brain and nerves The physician reviewer found that a patient has requested reimbursement for greater occipital nerve block. The patient met the clinical criteria for primary headache disorder, had migraines, and had failed multiple medications and other treatments. The…

   The physician reviewer found that a patient has requested reimbursement for greater occipital nerve block. The patient met the clinical criteria for primary headache disorder, had migraines, and had failed multiple medications and other treatments. The patient previously demonstrated improvement with an occipital nerve block. Published literature notes that occipital nerve blocks are often considered first‑line treatment and may serve both diagnostic and therapeutic purposes. Given the patient’s history of unsuccessful standard therapies and prior positive response, the occipital nerve block was indicated for this patient’s condition. Accordingly, the greater occipital nerve block was likely to have been more beneficial for the treatment of this patient’s condition than any available standard therapy.Findings: Three of the three reviewers found that the procedure at issue was 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 procedure at issue was 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 overturned. Credentials/Qualifications: Reviewer 1 is board-certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Reviewer 2 is board-certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Reviewer 3 is board-certified in neurology with subspecialty certifications in psychiatry and epilepsy 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 EI26-46639

4. Overturned 2025 · Medical necessity · age 65+ Knee gel injections (viscosupplementation) · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for Euflexxa series injections to the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it…

   The physician reviewer found that a patient has requested authorization and coverage for Euflexxa series injections to the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has osteoarthritis of the right knee and tried and failed other conservative treatments. Given the patient’s limited options and based on the current medical literature, Euflexxa series injections to the right knee 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 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 MN25-46339

5. Overturned 2025 · Medical necessity · age 51–64 Knee gel injections (viscosupplementation) · Bones, joints and muscles The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for a series of Orthovisc injections to the left knee and/or a series of Orthovisc injections to the right knee. According to the medical…

   The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for a series of Orthovisc injections to the left knee and/or a series of Orthovisc injections to the right knee. According to the medical literature, viscosupplementation is only recommended for patients with osteoarthritis of the knees with a history of lasting benefit from prior injections, and in patients who have tried and failed all other options and whose remaining options are limited. In this case, the records document that the patient has osteoarthritis of the left knee with chronic pain on standing and walking. The patient has tried and failed several conservative measures including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and bracing. As such, the patient’s remaining treatment options are clearly limited, and the patient has received viscosupplementation of the left knee with Orthovisc injections. Based on the results of viscosupplementation of the left knee, similar injections have been requested for the patient’s right knee. However, the records submitted do not sufficiently document the presence of osteoarthritis in the patient’s right knee. Overall, the records and medical literature do not support the use of Orthovisc injections for the patient’s right knee, but do support the use of Orthovisc injections for the management of the patient’s osteoarthritis of left knee. Therefore, the requested series of Orthovisc injections to the right knee is not medically necessary, while the series of Orthovisc injections to the left knee was medically necessary for the treatment of this patient. Final Result: The reviewer determined that a series of Orthovisc injections to the left knee 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 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 MN25-46331

6. Upheld 2025 · Medical necessity · age 51–64 Epidural injections · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a steroid injection. With regards to the evidence surrounding the requested epidural steroid injections, there is support in…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a steroid injection. With regards to the evidence surrounding the requested epidural steroid injections, there is support in the medical literature for the treatment of radicular pain. In this case, however, the records do not demonstrate that the patient presents with any radicular pain. The records suggest that the patient has axial low back pain only. There is a lack of demonstrated radiation in the records provided. Radicular pain involves pain into an extremity. Furthermore, magnetic resonance imaging (MRI) findings have shown no evidence of compression of a nerve root, which would lead to radicular pain. Overall, there is minimal to no evidence showing efficacy of epidural steroid injections for non-radicular pain. Given these findings, the requested steroid injection is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment is 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 anesthesiology with subspecialty certification in pain medicine 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 MN25-46266

7. Upheld 2025 · Medical necessity · age 51–64 Epidural injections · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a cervical/thoracic interlaminar epidural. According to a publication regarding epidural steroids for cervical and lumbar…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a cervical/thoracic interlaminar epidural. According to a publication regarding epidural steroids for cervical and lumbar radicular pain and spinal stenosis, “The review affirms limited efficacy of ESIs [epidural steroid injections] in reducing pain and disability in cervical and lumbar radiculopathies and possibly in lumbar spinal stenosis, largely in the short term.” Regarding nonoperative management of cervical radiculopathy, according to one pair of authors, “Patients should be reassured that most cases will resolve regardless of the type of treatment. Nonoperative treatment includes physical therapy involving strengthening, stretching, and potentially traction, as well as nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage. Epidural steroid injections may be helpful but have higher risks of serious complications. In patients with red flag symptoms or persistent symptoms after four to six weeks of treatment, magnetic resonance imaging can identify pathology amenable to epidural steroid injections or surgery.” The records do not demonstrate that the patient has yet begun physical therapy, though the patient is scheduled to begin soon. Given these findings, the requested cervical/thoracic interlaminar epidural is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment is 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 physical medicine and rehabilitation with subspecialty certifications in pain medicine and brain injury medicine 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 MN25-46245

8. Overturned 2025 · Medical necessity · age 65+ Knee gel injections (viscosupplementation) · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an Euflexxa injection series administered to the right knee. In this case, the patient has documented osteoarthritis of the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an Euflexxa injection series administered to the right knee. In this case, the patient has documented osteoarthritis of the right knee. The record reveals that conservative measures have been attempted, including physical therapy and home exercises. The patient is unable to take NSAIDs. Further, a review of the record establishes that cortisone injections have been ineffective for the patient. A review of the record establishes that the patient’s options are clearly limited, and the provider advised viscosupplementation with a series of Euflexxa injections to the right knee. As such, the requested Euflexxa injection series administered to the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service 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 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 MN25-46241

9. Overturned 2025 · Medical necessity · age 51–64 Steroid injections · Bones, joints and muscles 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…

   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 osteoarthritis of the right knee and has tried multiple conservative treatments, with decreasing relief over time. Remaining treatment options are limited. In this clinical setting, viscosupplementation is appropriate. Given these findings, the requested series of Euflexxa injections to the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46155

10. Upheld 2025 · Medical necessity · age 51–64 Other · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for platelet-rich plasma (PRP) injections. Rotator cuff tear is the most common shoulder pathology and is a condition with varied…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for platelet-rich plasma (PRP) injections. Rotator cuff tear is the most common shoulder pathology and is a condition with varied presenting features and a wide variety of management options. The mainstay of treatment for partial thickness cuff tear is systematic rehabilitation and for full thickness cuff tear an initial rehabilitation is an accepted management. In this case, the patient is being treated for a left shoulder torn rotator cuff. The patient presents with left shoulder pain. The patient’s exam revealed forward elevation 130 degrees active and 150 degrees passive, external rotation in abduction of 80 degrees, external rotation in abduction of 60 degrees, and internal rotation of L2. A painful arc has been noted, as well as tenderness to palpation at the acromioclavicular (AC) joint and biceps. Speed’s and Hawkin’s tests are reported as positive with a mildly positive Neer’s test. Strength is 4/5 in the supraspinatus with pain. The patient’s magnetic resonance imaging (MRI) of the left shoulder has impressions of supraspinatus with moderate to severe tendinosis and a 2 cm moderate partial thickness disruption. The patient’s provider has not recommended surgical intervention, but rather continuing conservative measures. The patient is requesting left shoulder PRP injections. According to a study, PRP “has gained popularity, especially in treating musculoskeletal conditions where the bulk of research has been performed and published. There is level I evidence available supporting its efficacy in the treatment of osteoarthritis (OA), epicondylitis, bursitis, compressive neuropathy, plantar fasciitis, muscular injuries and osteochondral lesions.” The authors noted that there is conflicting evidence with regard to tendinopathies and partial tendon tears. The need for further PRP studies is corroborated by another study noting, “Clinical studies continue to lag and are often heterogenous in quality and in results. PRP can vary widely based on multiple intrinsic and extrinsic factors, including patient age, sex, activity level, centrifugation speed, and number of centrifugation cycles. Thus, quality research methods should include reporting using the PAW (platelets/activation/white blood cells) system. Clinicians should remain cautiously optimistic about the future role of PRP injections in the shoulder.” Overall, a review of the medical literature shows that the evidence is insufficient to determine that PRP injections are standard medical treatment. There is a lack of randomized, blinded, clinical studies examining the benefits and long-term outcomes establishing the value of PRP in clinical management. There are limited large-scale, long-term studies showing the safety and efficacy of the requested PRP injection therapy in this patient’s clinical setting. Therefore, the requested PRP injections are 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 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 MN25-45972

11. Upheld 2025 · Medical necessity · age 41–50 Nerve blocks · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for diagnostic nerve blocks and related procedures for the evaluation and treatment of facial pain. Standard management of…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for diagnostic nerve blocks and related procedures for the evaluation and treatment of facial pain. Standard management of trigeminal neuralgia typically begins with pharmacologic therapy, with procedural or surgical interventions reserved for refractory cases. While various interventional approaches exist, current medical literature supports specific procedures with established long-term efficacy, whereas other peripheral nerve interventions and diagnostic blocks have limited evidence demonstrating durable benefit. In this case, the requested diagnostic and interventional procedures are not supported as optimal or necessary based on current evidence and accepted standards of care, particularly given concerns regarding limited long-term effectiveness and high recurrence rates associated with these approaches. Therefore, the requested 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 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 otolaryngology and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

    Case MN25-45797

12. Upheld 2025 · Medical necessity · age 51–64 Other · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for platelet-rich plasma (PRP) injections, either as monotherapy or in combination with other injectable therapies, for knee…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for platelet-rich plasma (PRP) injections, either as monotherapy or in combination with other injectable therapies, for knee osteoarthritis. Current clinical guidelines emphasize conservative management and established treatment options for this condition. The available medical literature does not provide consistent, high-quality evidence demonstrating that PRP injections offer superior or durable benefit compared to standard therapies. Additionally, there is insufficient evidence supporting combination injectable approaches as more effective than conventional care. In this case, there is no compelling clinical justification or extenuating circumstance supporting the use of the requested treatment as an exception to standard practice. Therefore, the requested PRP injections are 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 board-certified in orthopedic surgery and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

    Case MN25-45784