Antacids for Digestive System/ GI: 54.3% of denials overturned
In 35 California IMR decisions from 2002 to 2025, reviewers overturned 19 (54.3%). In the last five years: 100.0% of 5. 33 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 100.0% |
| 2023 | 1 | 100.0% |
| 2025 | 2 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 8 | 62.5% | 54.3% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 7 | 85.7% | 54.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 0.0% | 54.3% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 100.0% | 54.3% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Voquezna tablet. Clinical guidelines for the management of gastroesophageal reflux disease (GERD) recommend potassium-competitive acid blockers such as Voquezna when proton pump inhibitor therapy has been ineffective. Additionally, Voquezna is capable of superior and more consistent acid suppression than proton pump inhibitors. …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the brand-name medication, Dexilant. The request for brand-name Dexilant is supported in this case. Dexilant, unlike several other proton pump inhibitors (PPIs), is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dexlansoprazole capsules DR. Current medical literature indicates that there is no difference in the control and healing of gastroesophageal reflux disease (GERD) between proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, pantoprazole, and rabeprazole. Dexilant (generic name dexlansoprazole), unlike all PPIs, is …”
And one the reviewer upheld
“The physician reviewer found that an enrollee has requested authorization and coverage for omeprazole 40 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s abdominal pain. The submitted documentation does not support the medical necessity of the requested medication. American College of Gastroenterology guidelines for gastroesophageal reflux …”
- 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 Antacids denials for Digestive System/ GI overturned?
In 35 California IMR decisions from 2002 to 2025, reviewers overturned 19 (54.3%). In the last five years: 100.0% of 5. 33 were medical-necessity disputes, 2 experimental/investigational.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
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 they weigh the same things.
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.