Anti-Fungal denials: 42.2% overturned by independent reviewers
In 102 California IMR decisions from 2002 to 2026, reviewers overturned the plan 43 times (42.2%). In the last five years: 61.1% of 18. 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 |
|---|---|---|---|
| Infectious Disease | 57 | 52.6% | 75.0% of 8 |
| Foot Disorder | 20 | 30.0% | 66.7% of 3 |
| Ears/Nose/Throat | 6 | 16.7% | — |
| Skin Disorders | 5 | 40.0% | 100.0% of 1 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 100.0% |
| 2022 | 1 | 100.0% |
| 2023 | 1 | 0.0% |
| 2024 | 8 | 75.0% |
| 2026 | 4 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 12 | 50.0% | 42.2% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 12 | 41.7% | 42.2% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 0.0% | 42.2% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 8 | 75.0% | 42.2% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 5 | 0.0% | 42.2% |
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 reimbursement and prospective authorization and coverage for Jublia. The records document success with the past use of Jublia, supporting its efficacy for this patient’s condition. Given that the patient continues to require effective treatment for onychomycosis, the chronic nature of the condition, and the failure of …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cresemba. The records provided for review support a diagnosis of disseminated pulmonary and joint coccidioidomycosis. The patient was started on Cresemba since he failed treatment with the first-line antifungal, fluconazole, due to severe, progressive drug-related side effects. Thus, the patient requires treatment …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ciclopirox (Penlac), topical anti-fungal treatment. Onychomycosis can be challenging to treat due to the thickness of the nail plate. Researchers note that while oral medications have higher success rates than topical agents, oral treatments may also present challenges in cases of drug-to-drug …”
- 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 Anti-Fungal denials overturned?
In 102 California IMR decisions from 2002 to 2026, reviewers overturned the plan 43 times (42.2%). In the last five years: 61.1% of 18.
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.