Ambulance/Transport denials: 37.3% overturned by independent reviewers
In 67 California IMR decisions from 2005 to 2017, reviewers overturned the plan 25 times (37.3%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Digestive System/ GI | 9 | 11.1% | — |
| Respiratory System | 8 | 50.0% | — |
| Orth/Musculoskeletal | 8 | 12.5% | — |
| Trauma/ Injuries | 8 | 75.0% | — |
| Cardiac/Circ Problem | 8 | 37.5% | — |
| CNS/ Neuromusc Dis | 7 | 14.3% | — |
| Mental Disorder | 6 | 33.3% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 44 | 31.8% | 37.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 0.0% | 37.3% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 5 | 40.0% | 37.3% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 33.3% | 37.3% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance transportation services. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance services provided. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to …”
“Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement for air and ground ambulance services. Findings: The physician reviewer found that acute leukemias and their treatment are major emergencies in internal medicine. The standard of care is to use multi-agent chemotherapy followed by allogeneic hematopoietic stem cell transplant for patients with matched bone marrow. In this …”
- 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
How often were Ambulance/Transport denials overturned?
In 67 California IMR decisions from 2005 to 2017, reviewers overturned the plan 25 times (37.3%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.