Specialist and out-of-network referrals: 52% 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. Upheld 2026 · Medical necessity · age 41–50 Hosp inpat est/new/sub serv · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for admission to an acute care rehabilitation facility, including wound care and scheduled physical and occupational therapy. The patient’s spinal cord injury and associated…

   The physician reviewer found that a patient has requested authorization and coverage for admission to an acute care rehabilitation facility, including wound care and scheduled physical and occupational therapy. The patient’s spinal cord injury and associated pressure wounds are chronic, and the record does not show an acute change in medical or functional status requiring the intensity of services provided in acute inpatient rehabilitation. The patient’s current needs, including wound care and assistance with mobility and daily activities, can be managed at a lower level of care. Therefore, admission to an acute care rehabilitation facility is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service 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 and is actively practicing. The reviewer is an expert in the treatment of the member'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 MN26-46990

2. Upheld 2026 · Medical necessity · age 51–64 Office visit new/est patient · Brain and nerves The physician reviewer found that a patient has requested authorization and coverage for tertiary sleep medicine services. The patient has severe obstructive sleep apnea that has not responded to an initial CPAP trial and is currently being managed by a sleep…

   The physician reviewer found that a patient has requested authorization and coverage for tertiary sleep medicine services. The patient has severe obstructive sleep apnea that has not responded to an initial CPAP trial and is currently being managed by a sleep provider who is pursuing additional standard evaluations and interventions. The record does not demonstrate a clinical need for tertiary‑level services, as the patient’s care remains appropriate within the scope of general sleep medicine. Therefore, the requested tertiary sleep medicine services are not medically necessary for this patient. Final Result: The reviewer determined that the 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 internal medicine with subspecialty certifications in sleep medicine and pulmonary diseases 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 MN26-46984

3. Overturned 2026 · Medical necessity · age 21–30 Hosp inpat admin/disch serv · Mental health The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, the patient meets Level 3.1…

   The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, the patient meets Level 3.1 criteria. Based on the documentation, the patient requires this level of care due to needs identified across multiple ASAM dimensions and is not yet clinically stable enough to transition to a less intensive setting. The RTC level of care was and is consistent with generally accepted standards of mental health and substance use disorder treatment, and the services were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services were not and are not primarily for the economic benefit of the health plan or for the convenience of the patient or providers. Accordingly, RTC services (ASAM 3.1) were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in addiction 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 MN26-46973

4. Upheld 2026 · Medical necessity · age 65+ Int nurs facil new est patient · Hormones and metabolism The physician reviewer found that a patient has requested authorization and coverage for (1) skilled nursing facility services including physical therapy, occupational therapy and speech therapy, and/or (2) transfer to an acute rehabilitation center. Per the…

   The physician reviewer found that a patient has requested authorization and coverage for (1) skilled nursing facility services including physical therapy, occupational therapy and speech therapy, and/or (2) transfer to an acute rehabilitation center. Per the medical records, the patient has a history of chronic medical conditions and residual deficits following a stroke. The submitted records do not support that the patient requires the level of observation and treatment provided in terms of physician oversight and skilled nursing care. While the patient may continue to benefit from occupational, speech, and physical therapy and assistance or supervision, such services do not require the intensity of skilled therapy services provided in the skilled nursing facility setting. Therefore, (1) skilled nursing facility services including physical therapy, occupational therapy and speech therapy are not medically necessary for the treatment of this patient.The complexity of the patient’s nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary rehabilitation approach. The records do not support the degree of medical acuity that would require oversight by a rehabilitation physician in the acute inpatient rehabilitation setting. The patient does not require multiple intensive therapies or an intensive rehabilitation program. While the patient has had a decline from baseline levels of function and mobility and may benefit from therapies and supervision, such services may be provided in a different rehabilitation setting, such as outpatient care or home health services. As such, the patient does not require the intensity of therapies provided in acute inpatient rehabilitation. Therefore, (2) transfer to an acute rehabilitation center is not medically necessary for the treatment of this patient.

   Case MN26-46927

5. Overturned 2026 · Medical necessity · age 65+ Hosp inpat est/new/sub serv · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for long-term acute care hospital level of care.Long-term acute care hospitals are indicated for patients requiring prolonged…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for long-term acute care hospital level of care.Long-term acute care hospitals are indicated for patients requiring prolonged hospital-level services, including daily physician management and complex medical interventions that cannot safely be provided at a lower level of care. Patients appropriate for long-term acute care commonly demonstrate ongoing respiratory instability, ventilatory support requirements, or multisystem conditions requiring frequent reassessment and active therapeutic intervention.In this case, the records document recurrent nocturnal desaturation despite noninvasive ventilation and continuous positive airway pressure therapy, ongoing suctioning requirements associated with hypoxemia, and the need for continuous pulse oximetry monitoring. The patient additionally has persistent gastrointestinal dysmotility with recurrent emesis despite ventilatory management, including an episode associated with respiratory distress and clinically significant aspiration risk.The records further demonstrate need for intravenous prokinetic therapy after failed medication weaning attempts, indicating that symptoms were not adequately controlled with stable enteral management. Current medical literature and clinical practice guidelines support long-term acute care placement for patients with chronic respiratory failure, recurrent desaturation events, aspiration risk, and ongoing ventilatory support needs requiring intensive respiratory monitoring and multidisciplinary management.The combination of recurrent hypoxemia despite positive airway pressure therapy, suctioning requirements, continuous monitoring needs, persistent emesis with aspiration risk, and need for intravenous medication titration demonstrates ongoing respiratory and gastrointestinal instability requiring coordinated physician oversight and frequent intervention. Although skilled nursing facilities may manage stable tracheostomy and enteral feeding care, the documented instability exceeds the level of care typically available in that setting.Given these findings, the requested long-term acute care hospital level of care is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested 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 internal medicine with subspecialty certifications in pulmonary diseases and critical care 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 MN26-46739

6. Upheld 2026 · Medical necessity · age 41–50 Sub nursing facil care · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing facility services. According to the medical records, the patient has necrotizing fasciitis and a diabetic foot…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing facility services. According to the medical records, the patient has necrotizing fasciitis and a diabetic foot wound status post left transtibial amputation, along with type 2 diabetes mellitus, asthma, Crohn’s disease, hyperlipidemia, and hypertension.The records do not contain sufficient documentation demonstrating the need for daily skilled nursing services such as complex wound management, tracheostomy care, bowel or bladder training, tube feeding, or administration of intravenous medications. Although the patient may continue to benefit from physical therapy, occupational therapy, and assistance or supervision, the submitted records do not establish that the patient requires the intensity of skilled therapy services provided in a skilled nursing facility setting.Given these findings, skilled nursing facility 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 physical medicine and rehabilitation 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 MN26-46706

7. Upheld 2026 · Medical necessity · age 31–40 Sub nursing facil care · Heart and circulation The physician reviewer found that a patient has requested authorization and coverage for re‑admission to the skilled nursing facility (SNF) level of care. The patient was initially hospitalized for acute heart failure, acute kidney injury, respiratory…

   The physician reviewer found that a patient has requested authorization and coverage for re‑admission to the skilled nursing facility (SNF) level of care. The patient was initially hospitalized for acute heart failure, acute kidney injury, respiratory failure, and atrial fibrillation, and was later discharged from an SNF to custodial long‑term care. The record shows that the patient is medically stable, tolerating a regular cardiac diet and thin liquids, does not require supplemental oxygen, and is taking oral medications. The patient does not require daily skilled nursing services such as complex wound care, tracheostomy care, bowel or bladder training, tube feeding, or IV medication administration. The patient is independent with eating, toileting, hygiene, and upper‑body dressing, and requires only supervision or touch assistance for showering and lower‑body dressing. Although the patient experienced a decline in ambulation due to right‑sided ankle and foot pain and continues to need some assistance with mobility and activities of daily living, these needs do not require the intensity of skilled therapy services provided in an SNF. The patient may continue to benefit from occupational and physical therapy, as well as assistance or supervision, but these services can be provided at a lower level of care. Accordingly, the requested re‑admission to the SNF level of care is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is not medically necessary for the treatment of the patient's medical conditions. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation 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 MN26-46627

8. Overturned 2026 · Medical necessity · age 65+ Office visit new/est patient · Digestive system The physician reviewer found that a patient has requested authorization and coverage for (1) preoperative consultation with a quaternary gastrointestinal (GI) specialist and/or (2) a hospital‑based optical colonoscopy provided by a quaternary GI specialist…

   The physician reviewer found that a patient has requested authorization and coverage for (1) preoperative consultation with a quaternary gastrointestinal (GI) specialist and/or (2) a hospital‑based optical colonoscopy provided by a quaternary GI specialist. Per the medical records, the patient has a very high risk for cardiovascular events during colonoscopy due to a history of coronary artery disease requiring prior interventions, with an elevated risk of an acute coronary event due to a history of hypertension, coronary artery disease, hyperlipidemia, and diabetes. In the event of a cardiovascular event during colonoscopy, this patient requires rapid access to specialized cardiovascular care and possible immediate cardiovascular intervention due to a history of prior coronary stent placement, which may make further coronary intervention challenging and require specialized catheterization equipment. Therefore, (1) preoperative consultation with a quaternary GI specialist and (2) a hospital‑based optical colonoscopy provided by a quaternary GI specialist are medically necessary for the evaluation 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 internal medicine with subspecialty certification in gastroenterology 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 MN26-46617

9. Upheld 2026 · Medical necessity · age 21–30 Hosp inpat admin/disch serv · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the hospital stay. In this case, the patient presented with an elevated heart rate, other symptoms, and a nosebleed. Computed tomography of…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the hospital stay. In this case, the patient presented with an elevated heart rate, other symptoms, and a nosebleed. Computed tomography of the head revealed no acute findings, and the patient did not exhibit dyspnea, chest pain, or hemodynamic instability. The patient was diagnosed with benign paroxysmal positional vertigo and administered intravenous fluids with complete resolution of symptoms. Treatment of benign paroxysmal positional vertigo can be performed at lower levels of care, including in the outpatient setting. Overall, this patient had no unstable co-morbid conditions or hemodynamic instability, and no advanced monitoring or procedures were performed in this case. The patient did not meet the criteria for inpatient admission. All told, the hospital stay was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service was 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 internal 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 MN26-46545

10. Overturned 2026 · Medical necessity · age 51–64 Gen behav integrat care mgmt · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services for the time period under review. ASAM criteria evaluate six dimensions to determine the appropriate level of care, including intoxication and withdrawal risk, biomedical conditions, psychiatric and cognitive conditions, substance use-related risks, recovery environment, and patient-centered considerations.Using ASAM Level 3.1 criteria, the patient meets all dimensional criteria for medical necessity and qualifies for this level of care. The RTC services were and are in accordance with generally accepted standards of mental health and substance use disorder care and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services are not primarily for the convenience of the patient or provider. Therefore, RTC services (ASAM 3.1) were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in addiction 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 MN26-46387

11. Overturned 2026 · Experimental or investigational · age 11–20 Office visit new/est patient · Diseases of Blood The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for mast cell infusion regimen composed of slow infusion of 2 liters normal saline, then additional medications including low dose…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for mast cell infusion regimen composed of slow infusion of 2 liters normal saline, then additional medications including low dose diphenhydramine, ondansetron, famotidine, diphenhydramine, and ketorolac once every 30 to 45 minutes over 4 to 5 hours, including office visit, normal saline infusion, infusion supplies including pump, diphenhydramine, ondansetron, famotidine, diphenhydramine, ketorolac, and intravenous push and infusion services.The records document diagnoses of mast cell activation syndrome and small intestinal bacterial overgrowth. The treating provider recommended infusion therapy including diphenhydramine, diazepam, ondansetron, and famotidine. A small retrospective study described benefit from continuous diphenhydramine infusions in patients with mast cell activation syndrome. Another study referenced use of diphenhydramine, the components of the proposed therapy, and treatment guidelines from the National Comprehensive Cancer Network and the American Academy of Allergy, Asthma, and Immunology.However, current National Comprehensive Cancer Network and American Academy of Allergy, Asthma, and Immunology guidelines emphasize trigger avoidance, medication-based symptom management, and individualized treatment strategies for mast cell activation syndrome. The guidelines do not specifically support the requested combination infusion regimen. Although diphenhydramine infusion may provide benefit, the remaining components of the requested regimen lack sufficient supporting evidence demonstrating superiority over available standard therapy.Given these findings, the requested mast cell infusion regimen including slow infusion of 2 liters normal saline and associated infusion medications and services is not likely to be more beneficial for treatment of the patient than available standard therapy, except for diphenhydramine infusion therapy, which is likely to be more beneficial for treatment of the patient than available standard therapy.Findings: Two of the three reviewers found that a portion of the requested services is likely to be more beneficial for the treatment of the patient’s medical condition than available standard therapy. Final Result: The reviewers determined that a portion of the requested services is likely to be more beneficial for the treatment of the patient’s medical condition than available standard therapy. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications: Reviewer 1 is board-certified in hematology with subspecialty certification in medical oncology and is actively practicing. Reviewer 2 is board-certified in internal medicine with subspecialty certification in hematology and medical oncology and is actively practicing. Reviewer 3 is board-certified in medical oncology with subspecialty certification in hematology 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 EI26-46756

12. Overturned 2025 · Medical necessity · age 41–50 Out-of-network referral · Cancer The physician reviewer found that a patient has requested authorization and coverage for a tertiary level of care for a bilateral mastectomy with immediate reconstruction (bilateral deep flap reconstruction). Medical literature notes that bilateral deep…

    The physician reviewer found that a patient has requested authorization and coverage for a tertiary level of care for a bilateral mastectomy with immediate reconstruction (bilateral deep flap reconstruction). Medical literature notes that bilateral deep inferior epigastric perforator flap reconstruction is associated with higher procedural complexity and increased risk of complications compared to unilateral procedures. The procedure in this case is lengthy and complex, and a short operative time is strongly correlated with successful outcomes and the avoidance of serious complications. According to the literature, the performance of this procedure by an experienced surgical team in an appropriately equipped tertiary care institution is medically necessary. All told, the requested tertiary level of care for a bilateral mastectomy with immediate reconstruction (bilateral deep flap reconstruction) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested 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 plastic 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 MN25-46347