Anti-inflammatories for Respiratory System: 50.0% of denials overturned
In 6 California IMR decisions from 2004 to 2025, reviewers overturned 3 (50.0%). In the last five years: 50.0% of 2. 4 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 1 | 100.0% |
| 2025 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab-pvvr, biosimilar, (Ruxience) 1,000 mg. In this case, the patient's history appears most consistent with interstitial pneumonia with autoimmune features (IPAF). She has responded well to steroid therapy and demonstrated clinical improvement with a trial with Rituxan. In this clinical setting, while it appears that the patient …”
“A 44-year-old male enrollee has requested Levaquin for the treatment of his rhinosinusitis. Findings: The physician reviewer found that the submitted clinical evidence demonstrates that the patient was treated with a variety of antibiotics for several months for sinusitis that had been present. His condition did not appear to improve significantly and sinus surgery was performed. The organism recovered at …”
“The patient is a 55-year-old woman with bronchial asthma and upper respiratory tract allergies. She had been treated with allergy immunotherapy and antiallergic /antiasthmatic therapy. It is stated that the patient occasionally required pulse steroids and was using sodium cromolyn and beta agonists. She did not want to use inhaled steroids as she was diagnosed with osteoporosis. Subsequently, the patient …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a Brinsuptri (brensocatib) tablet. Brensocatib is approved for non-cystic fibrosis bronchiectasis in individuals over 12 years of age. It is generally considered as add-on therapy for patients who continue to have exacerbations despite treatment with a macrolide or inhaled antipseudomonal antibiotic.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 Anti-inflammatories denials for Respiratory System overturned?
In 6 California IMR decisions from 2004 to 2025, reviewers overturned 3 (50.0%). In the last five years: 50.0% of 2. 4 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.