Anti-virals for Infectious Disease: 82.6% of denials overturned
In 1310 California IMR decisions from 2003 to 2025, reviewers overturned 1082 (82.6%). In the last five years: 70.0% of 20. 1296 were medical-necessity disputes, 14 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 8 | 62.5% |
| 2022 | 2 | 50.0% |
| 2023 | 3 | 66.7% |
| 2024 | 6 | 83.3% |
| 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. | 747 | 87.1% | 82.6% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 196 | 83.7% | 82.6% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 82 | 89.0% | 82.6% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 75 | 68.0% | 82.6% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 61 | 39.3% | 82.6% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 43 | 18.6% | 82.6% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 39 | 74.4% | 82.6% |
| Urgent or emergencyThe findings mention urgency. | 16 | 56.3% | 82.6% |
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 Epclusa. 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 those with limited life …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient with hepatitis B has requested authorization and coverage for Vemlidy. Per the medical records, given that the patient has been stabilized on Vemlidy, with a suppressed viral load, a change in therapy to a potentially less effective medication, such as entecavir, or a medication with more renal toxicity, …”
“The physician reviewer found that the patient has requested authorization and coverage for Vemlidy. The American Association for the Study of Liver Disease (AASLD) guidelines for the treatment of Hepatitis B recommend entecavir and tenofovir compared with alternatives for the treatment of chronic Hepatitis B. Researchers report that in comparison with Viread (tenofovir disoproxil fumarate), the Vemlidy formulation of tenofovir …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Cabenuva injections every other month. Cabenuva is currently approved for treatment of virologically suppressed human immunodeficiency virus (HIV) patients switching antiretroviral therapy (ART) regimens. It is not approved as an initial regimen for HIV treatment in treatment-naive patients. Cabenuva has not been …”
- 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 Infectious Disease overturned?
In 1310 California IMR decisions from 2003 to 2025, reviewers overturned 1082 (82.6%). In the last five years: 70.0% of 20. 1296 were medical-necessity disputes, 14 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.