What independent reviewers decided, treatment by treatment
The dataset is temporarily unavailable. The pages below will fill in when the database is reachable.
By treatment (most reviewed first)
Data temporarily unavailable.
- 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?
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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.
Every treatment category with 20 or more decisions
Alphabetical. Each page shows the diagnosis breakdown, the arguments that appear in overturned decisions, and attributed excerpts from the reviewers.