Bone Fracture/Break denials at external review

• among the lowest

  At 27.0%, this is the 7th-lowest overturn rate of the 72 conditiones carrying one — one of the few where reviewers more often agreed with the plan than not.

• American College of Rheumatology—3
• American Academy of Orthopaedic Surgeons—1
• FDA—1

A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.

• Skilled nursing & inpatient rehab—11
• Durable medical equipment—9
• Diagnostic imaging & screening—5
• Orthopedic procedures—5
• Outpatient rehabilitation—2
• Acute inpatient medical—1
• Cardiovascular procedures—1
• Home Health Care—1

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• Inpt Admission—6
• Other—6
• MRI—5
• Elect Bone Stim—4
• Inpt Discharge—4
• Electric Scooter—2
• Admission—1
• Electric Wheelchair—1

• Medical Necessity27.3%33
• Experimental/Investigational—4

Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.