Anti-inflammatories for Skin Disorders: 60.0% of denials overturned
In 30 California IMR decisions from 2015 to 2025, reviewers overturned 18 (60.0%). In the last five years: 83.3% of 6. 29 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2025 | 4 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 10 | 40.0% | 60.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 0.0% | 60.0% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 7 | 14.3% | 60.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 66.7% | 60.0% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 5 | 80.0% | 60.0% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 60.0% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 3 | 100.0% | 60.0% |
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 Remicade infusions. The American Academy of Dermatology guidelines for the management of hidradenitis suppurativa recommend infliximab for the treatment of moderate to severe disease. Per the medical records, the patient has severe hidradenitis suppurativa and has been receiving Remicade with stable control …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested authorization and coverage for a systemic medication for atopic dermatitis. The requested medication is approved for the treatment of moderate to severe atopic dermatitis in appropriate patients. Clinical guidelines support escalation to systemic therapy in patients who have not achieved adequate control with prior …”
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Dupixent. The U.S. Food and Drug Administration (FDA) approves using Dupixent to treat moderate-severe atopic dermatitis that is not adequately controlled with topical prescription therapies. Current medical literature concludes that the most robust, replicated high-quality trial evidence is present for the efficacy and safety of dupilumab. Per …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade infusions administered every five (5) weeks. The U.S. Food and Drug Administration (FDA) approves the use of Remicade for the treatment of chronic severe plaque psoriasis, psoriatic arthritis, and ulcerative colitis. The FDA approved dosage is at eight-week intervals. In this case, the patient is being …”
- 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 Skin Disorders overturned?
In 30 California IMR decisions from 2015 to 2025, reviewers overturned 18 (60.0%). In the last five years: 83.3% of 6. 29 were medical-necessity disputes, 1 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.