Anti-virals for Digestive System/ GI: 60.0% of denials overturned
In 10 California IMR decisions from 2005 to 2025, reviewers overturned 6 (60.0%). In the last five years: 100.0% of 1. 10 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2025 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 75.0% | 60.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 75.0% | 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 a patient has requested authorization and coverage for Vemlidy. Per the medical records, the patient has a diagnosis of chronic hepatitis B. The American Association for the Study of Liver Disease (AASLD) guidelines for the treatment of hepatitis B recommend entecavir and tenofovir. Given that guidelines and current medical literature support the efficacy of Vemlidy …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollee’s small intestinal bowel overgrowth (SIBO). Findings: The physician reviewer found that as noted in the medical literature SIBO is characterized by an increased number of endogenous symbiotic bacteria in the small bowel and can lead to uncomfortable symptoms …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C should be treated except …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90/400 mg for 12 weeks for treatment of the enrollee’s hepatitis C.Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic …”
- 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-virals denials for Digestive System/ GI overturned?
In 10 California IMR decisions from 2005 to 2025, reviewers overturned 6 (60.0%). In the last five years: 100.0% of 1. 10 were medical-necessity disputes.
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.