What independent reviewers decided, treatment by treatment
California publishes every Independent Medical Review decision since 2001: 42,710 cases where a member took a denial to an outside physician. Reviewers overturned the plan in 52.5% of them. This library shows the rate for each treatment and diagnosis with its N, what the findings mention in overturned cases, and short attributed excerpts.
By treatment (most reviewed first)
| Treatment (DMHC label) | Category | Decisions | Overturned | Years |
|---|---|---|---|---|
| Weight Control | Pharmacy | 1,581 | 86.3% | 2001–2026 |
| RTC | Mental Health | 1,390 | 80.5% | 2019–2026 |
| Anti-virals | Pharmacy | 1,351 | 81.4% | 2003–2026 |
| MRI | Diag Imag & Screen | 1,068 | 42.8% | 2001–2026 |
| RTC/ Admit | Mental Health | 1,061 | 41.5% | 2002–2020 |
| Lab Work | Diag Imag & Screen | 1,015 | 31.6% | 2005–2026 |
| Speech Therapy | Autism Related Tx | 972 | 73.9% | 2002–2026 |
| Hormones | Pharmacy | 971 | 43.0% | 2001–2026 |
| Viscosupp Injection | Pain Management | 844 | 93.8% | 2018–2026 |
| Mammography | Diag Imag & Screen | 784 | 93.2% | 2006–2021 |
| Genetic/Genomic Test | Diag Imag & Screen | 582 | 51.7% | 2018–2026 |
| Biologics | Pharmacy | 527 | 78.2% | 2006–2026 |
| Skin Treatment | Pharmacy | 519 | 69.0% | 2002–2026 |
| Botox Injection | Pharmacy | 517 | 58.0% | 2001–2026 |
| Appld Behav Analysis | Autism Related Tx | 481 | 69.4% | 2006–2025 |
| Emergency Room | Emergency/Urg Care | 471 | 46.5% | 2002–2025 |
| Pain Medication | Pain Management | 459 | 32.2% | 2017–2026 |
| CT Scan | Diag Imag & Screen | 433 | 30.3% | 2002–2025 |
| Pet Scan | Diag Imag & Screen | 429 | 59.4% | 2002–2025 |
| Physical Therapy | Autism Related Tx | 416 | 34.6% | 2001–2025 |
| Arthritis Rx | Pharmacy | 400 | 56.0% | 2001–2026 |
| Partial Hospital | Autism Related Tx | 386 | 62.7% | 2002–2026 |
| IVIG Therapy | Pharmacy | 385 | 49.1% | 2002–2026 |
| Non-FDA Approved Use | Pharmacy | 383 | 43.6% | 2002–2011 |
| Acute Psych/ Admit | Mental Health | 362 | 56.1% | 2002–2020 |
| SCP Consult Refer | Diag/ MD Eval | 348 | 59.2% | 2001–2025 |
| TMS | Elect/Therm/Radfreq | 321 | 56.7% | 2010–2025 |
| Radiofreq Ablat | Elect/Therm/Radfreq | 317 | 42.9% | 2002–2025 |
| Proton Beam | Cancer Care | 315 | 34.0% | 2005–2025 |
| Intensive Outpt Prog | Mental Health | 309 | 71.5% | 2017–2025 |
| Inpt Admission | Rehab/Svcs SNF Inpt | 301 | 25.6% | 2002–2025 |
| RTC/Discharge | Mental Health | 289 | 40.5% | 2006–2020 |
| Diabetic Medication | Pharmacy | 288 | 74.7% | 2017–2026 |
| Occupational Therapy | Autism Related Tx | 276 | 64.1% | 2002–2025 |
| Anti-inflammatories | Pharmacy | 266 | 52.6% | 2003–2026 |
| Chemotherapy | Cancer Care | 263 | 41.4% | 2002–2021 |
| Nerve Block | Pain Management | 247 | 59.1% | 2003–2026 |
| Fusion | Neurosurgery Proc | 246 | 28.0% | 2003–2025 |
| Artificial Disc Repl | Orthopedic Proc | 244 | 9.8% | 2005–2025 |
| Digestion/GI Rx | Pharmacy | 229 | 79.5% | 2019–2026 |
| Admission | Acute Med Svc Inpt | 211 | 51.7% | 2002–2026 |
| Gastric Bypass | Gen Surg proc | 210 | 59.0% | 2001–2005 |
| Acupuncture | Alternative Tx | 205 | 39.5% | 2002–2025 |
| Antibiotics | Pharmacy | 202 | 41.6% | 2001–2026 |
| Formulary v Non Form | Pharmacy | 197 | 39.6% | 2003–2011 |
| OON Referral | Diag/ MD Eval | 183 | 27.3% | 2002–2025 |
| Cardiac Rx | Pharmacy | 180 | 38.9% | 2002–2026 |
| Analgesics | Pharmacy | 179 | 20.1% | 2002–2017 |
| Radiation Therapy | Cancer Care | 178 | 56.7% | 2002–2025 |
| Panniculectomy | Reconstr/Plast Proc | 178 | 33.1% | 2001–2026 |
| Bariatric Other | Gen Surg Proc | 174 | 51.1% | 2002–2019 |
| Migraine Rx | Pharmacy | 172 | 83.1% | 2018–2026 |
| Epidural Injection | Pain Management | 169 | 45.0% | 2002–2026 |
| Psychotherapy | Autism Related Tx | 168 | 52.4% | 2008–2025 |
| Surgery | Cancer Care | 168 | 52.4% | 2002–2026 |
| Breast reduction | Reconstr/Plast Proc | 165 | 56.4% | 2002–2025 |
| Electric Wheelchair | DME | 160 | 23.1% | 2001–2025 |
| Sinus Surgery | Ear-Nose-Thro Proc | 155 | 63.9% | 2009–2026 |
| Radiation Oncology | Cancer Care | 149 | 38.9% | 2003–2015 |
| General Anesthesia | Special Proc | 148 | 25.7% | 2006–2025 |
Most reviewed treatment and diagnosis pairs
| Treatment | Diagnosis | Decisions | Overturned |
|---|---|---|---|
| Weight Control | Endocrine/Metabolic | 1,371 | 87.5% |
| RTC | Mental Disorder | 1,351 | 80.2% |
| Anti-virals | Infectious Disease | 1,310 | 82.6% |
| RTC/ Admit | Mental Disorder | 1,031 | 41.3% |
| Viscosupp Injection | Orth/Musculoskeletal | 824 | 93.9% |
| Hormones | Endocrine/Metabolic | 547 | 42.8% |
| MRI | Orth/Musculoskeletal | 527 | 39.7% |
| Speech Therapy | Pediatrics | 482 | 75.9% |
| Mammography | Prevention/Good Hlth | 473 | 93.9% |
| Appld Behav Analysis | Autism Spectrum | 459 | 71.2% |
| Skin Treatment | Skin Disorders | 448 | 67.4% |
| Partial Hospital | Mental Disorder | 356 | 62.9% |
| Speech Therapy | Autism Spectrum | 354 | 73.7% |
| Acute Psych/ Admit | Mental Disorder | 346 | 55.5% |
| Botox Injection | CNS/ Neuromusc Dis | 335 | 62.4% |
| Genetic/Genomic Test | Cancer | 328 | 49.1% |
| TMS | Mental Disorder | 314 | 56.7% |
| Proton Beam | Cancer | 307 | 34.2% |
| Pet Scan | Cancer | 305 | 69.2% |
| Intensive Outpt Prog | Mental Disorder | 291 | 71.8% |
| RTC/Discharge | Mental Disorder | 283 | 41.0% |
| Pain Medication | Orth/Musculoskeletal | 268 | 33.2% |
| Diabetic Medication | Endocrine/Metabolic | 263 | 75.3% |
| Lab Work | Cancer | 256 | 42.2% |
| Chemotherapy | Cancer | 252 | 40.9% |
| Fusion | Orth/Musculoskeletal | 243 | 28.0% |
| Mammography | OB-GYN/ Pregnancy | 242 | 91.7% |
| Artificial Disc Repl | Orth/Musculoskeletal | 239 | 9.6% |
| Physical Therapy | Orth/Musculoskeletal | 236 | 27.5% |
| Arthritis Rx | Orth/Musculoskeletal | 234 | 53.0% |
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
What is an Independent Medical Review?
In California, a member whose plan denied a service as not medically necessary, experimental or not urgent can ask the Department of Managed Health Care for an Independent Medical Review. An outside physician reviews the record and the decision binds the plan. The department publishes every decision since 2001 as open data.
How often do reviewers overturn the plan?
Across 42,710 decisions from 2001 to 2026, reviewers overturned the plan in 52.5% of cases. The rate varies widely by treatment and diagnosis; the tables show each with its N.
Does this apply outside California?
Not directly. Other states run their own external review with different reviewers; self-funded employer plans use the federal process. The reasoning in the findings, however, is the same kind of reasoning any reviewer applies: criteria, documentation, alternatives tried.
Can I read a specific decision?
This library publishes aggregates and short attributed excerpts. The full decisions are searchable on the Department of Managed Health Care's website and in the CHHS open data file linked on every page.
See also the External Review Index (state reversal rates) and the Insurer Denial Report Cards.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.