In Maryland’s 2003 review of medical necessity appeals:

• consumers were successful about half the time (46%, or 175 of 378 cases), either because the health plan reversed itself during the investigation (29%, or 111 cases), or the health plan’s decision was reversed by the reviewers (17%, or 64 cases);   
• the health plan’s decision was modified by the reviewers 3% of the time (11 cases); and
• the health plan’s decision was upheld 51% of the time (192 cases).  

In Maryland, consumers were less likely to win in certain types of cases.  For example, reviewers ruled in favor of the health plan in 93% of appeals for cosmetic procedures, 93% of appeals for treatment of morbid obesity, and 69% of appeals regarding physician services (though the health plans later reversed themselves during 27% of physician services appeals).⁽¹¹⁾

In North Carolina, consumers were granted relief through external review 45% of the time (43% of the health plan denials were overturned and in 2% of the cases, health plans reversed their denials decisions) during 2003 and 2004.  In 2003, Maine consumers were successful 57% of the time (43% full reversals and 14% partial reversals of the health plan denials).  The success rate for Texans who appealed in 2004 was 57% (49% in favor of the consumer and 8% partially in favor of both the consumer and the HMO).  The success rate was 42% in Indiana in 2003, 39% in California in 2004, and 42% in New York in 2003 (35% health plan denials were reversed in full and 7% were reversed in part).⁽¹²⁾

An earlier study with data from the late 1990s and early 2000s found that, on average, consumers were granted relief through external review almost half (45%) of the time.  However, the percent varied by state, from a low of 21% in Arizona and Minnesota to a high of 72% in Connecticut.  In addition, in about half of the states, reviewers could partially overturn a health plan denial, which they did, on average, 6% of the time.⁽¹³⁾

⁽¹¹⁾ The Maryland Insurance Administration’s 2003 Report on The Health Care Appeals & Grievance Law, August 2004, pp. 8-9 and unnumbered Appendix, at http://www.mdinsurance.state.md.us/documents/AppealsandGreivanceReport2003.pdf.

⁽¹²⁾ “Success rate” is used to indicate the ratio of the number of appeals wholly or partially resolved in favor of the consumer (including reversals by the health plan, if noted) to the number of appeals closed during the period.  Data sources:  North Carolina: Healthcare Review Program Semiannual Report for the period of January 1, 2003-December 31, 2004, pp. 11-12, at  http://www.ncdoi.com/Consumer/ERP/ExternalReviewReport5.pdf;  Maine: 2003 Maine Consumer Guide to Health Insurers, at http://www.state.me.us/pfr/ins/HealthGuide_External_Review.htm;  Texas: Complaint Data, Comparing Texas HMOs 2004. p. 109, at  http://www.opic.state.tx.us/docs/295_complaint2004.pdf;  Indiana: 2003 Indiana External Reviews, at http://www.in.gov/idoi/health/2003_external_review_report.html;  California: Annual Report 2004, Department of Managed Health Care, Appendix A, pp. 29-30, at http://www.hmohelp.ca.gov/library/reports/complaint/2004.pdf;  New York: 2004 New York Consumer Guide to Health Insurers, pp. 29-31, at http://www.ins.state.ny.us/acrobat/hg2004.pdf.