Federal IDR outcomes: Plastic and reconstructive surgery

In 2025 Q1–Q4, the provider or facility offer prevailed in 89.3% of 36,612 determined Federal IDR dispute line items for plastic and reconstructive surgery. The median prevailing offer was 20.16x the QPA (25th–75th percentile 7.72x–52.28x; n = 32,015). The median time to a decision was 33 business days (n = 36,612).

Specialty group built from the CMS free-text specialty field; see the grouping rules.

Determined line items

36,612

2025 Q1–Q4 · 60 split decisions excluded

Provider win rate

89.3%

n = 36,612 · 2025 Q1–Q4

Median payment vs QPA

20.16x †

middle half 7.72x–52.28x · n = 32,015 · 2025 Q1–Q4

Median days to decision

business days, from dispute initiation · n = 36,612 · 2025 Q1–Q4

Dollar amounts are not shown for specialty groups: the CMS QPA and Offers file, the only source of dollar figures, has no specialty field. See methodology.

By period

Period	Line items	Win %	Median ×QPA	25th–75th	Ratio n	Median days
2025 Q1–Q4	36,612	89.3%	20.16x †	7.72x–52.28x	32,015	33
2024 Q1–Q4	16,702	88.9%	16.75x	6.80x–38.25x	14,792	50
2023 Q1–Q4	2,067	82.1%	13.00x	5.13x–25.18x	2,029	69
2023 Q1–2025 Q4	55,381	88.9%	18.60x	7.16x–46.44x	48,836	not pooled

Line items = determined dispute line items (n). Win rate excludes split decisions and includes default decisions. Ratio n = line items reporting a payment-to-QPA ratio. Days are business days as reported by CMS (2023–2024: from IDR entity assignment; 2025: from initiation) and are never pooled.

By state

State (place of service)	Line items	Win %	Median ×QPA	Ratio n	Median days
New York	13,107	87.5%	24.74x †	12,247	31
New Jersey	11,149	89.1%	24.13x †	9,709	36
Connecticut	3,199	92.7%	30.74x †	1,623	32
Florida	2,077	95.3%	12.42x	1,756	35
Virginia	2,024	89.3%	8.07x	1,977	35
California	1,534	87.4%	36.46x †	1,403	28
Texas	1,305	94.9%	12.79x	1,259	48
Massachusetts	555	88.5%	15.06x	539	38
Arizona	509	91.0%	16.72x	480	25
Georgia	229	90.0%	62.22x †	186	25
Pennsylvania	156	76.3%	5.11x	150	23
Alabama	152	84.9%	5.15x	145	23
Louisiana	139	90.6%	11.08x	137	32
Colorado	98	90.8%	10.63x	95	25
Arkansas	76	96.1%	5.30x	73	88
Illinois	62	95.2%	8.68x	32	29
Delaware	57	89.5%	10.60x	54	43
Washington	47	76.6%	79.86x †	47	28
Rhode Island	34	88.2%	–	24	25.5
New Hampshire	31	96.8%	–	9	30

2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.

Most disputed CPT codes

CPT code	Line items	Win %	Median ×QPA	Ratio n	Median days
19318 Breast reduction	2,741	85.8%	43.47x †	2,452	31
14301 Repair of wound by transferring skin, 30.1-60.0 sq cm	1,559	87.3%	19.95x	1,407	32
14302 Repair of wound by transferring skin, each additional 30.0 sq cm	1,339	87.5%	18.54x	1,181	34
15734 Creation of muscle graft to trunk	1,085	86.7%	16.96x	946	34
19380 Surgical change to reconstructed breast	1,017	91.5%	27.82x †	845	32
99283 Emergency department visit with low level of medical decision making	998	89.9%	15.15x	944	41
13131 Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, g	973	89.6%	32.47x †	910	34
19357 Reconstruction of breast using tissue expander	965	88.2%	20.77x †	837	33
15777 Implantation of biologic implant to soft tissue	899	90.9%	36.48x †	773	33
15002 Preparation of skin graft site of trunk, arms, or legs, 100.0 sq cm or 1% body a	766	90.7%	21.84x †	688	34
15771 Graft using patient's fat removed by liposuction and inserted into trunk, breast	710	91.1%	20.46x †	597	30.5
13132 Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, g	631	91.3%	24.30x †	542	36
13152 Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm	620	86.3%	29.61x †	550	34
19364 Reconstruction of breast with tissue graft	604	92.5%	21.08x †	530	36
19371 Removal of capsule around breast implant	575	88.9%	39.13x †	486	31
15772 Graft using patient's fat removed by liposuction and inserted into trunk, breast	551	90.9%	28.43x †	473	31
13151 Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm	550	88.5%	29.95x †	517	34
19342 Placement of implant on separate day of breast reconstruction	461	91.8%	20.82x †	384	30
13102 Complicated repair of wound of trunk, each additional 5.0 cm or less	419	89.3%	20.94x †	356	32
13101 Complicated repair of wound of trunk, 2.6-7.5 cm	402	90.3%	12.33x	330	33
38530 Biopsy or removal of lymph nodes of breast	377	89.1%	35.28x †	296	31
15004 Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, aroun	326	90.5%	14.09x	319	32
15830 Removal of extra skin and tissue of abdomen	299	84.9%	25.31x †	281	31
19350 Reconstruction of nipple or area around nipple	289	91.0%	27.68x †	231	32
99284 Emergency department visit with moderate level of medical decision making	286	89.2%	6.52x	235	36

2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.

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FAQ

What is the Federal IDR provider win rate for plastic and reconstructive surgery?

In 2025 Q1–Q4, the provider or facility offer was selected in 89.3% of 36,612 determined dispute line items for plastic and reconstructive surgery. Split decisions are excluded from the denominator and default decisions are included. Withdrawn, settled and ineligible disputes are not in the CMS data.

How do Federal IDR payments compare with the QPA for plastic and reconstructive surgery?

In 2025 Q1–Q4, the median prevailing offer was 20.16x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 7.72x to 52.28x (n = 32,015 line items). This uses the CMS field Prevailing Party Offer as % of QPA, where 1.00x equals the QPA.

How long do Federal IDR decisions take for plastic and reconstructive surgery?

In 2025 Q1–Q4, the median was 33 business days (n = 36,612 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).

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