Anti-virals for Respiratory System: 58.3% of denials overturned
In 12 California IMR decisions from 2007 to 2025, reviewers overturned 7 (58.3%). In the last five years: 50.0% of 2. 11 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 1 | 100.0% |
| 2025 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 33.3% | 58.3% |
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: The patient requested authorization and coverage for Prevymis 480 mg tablets.Cytomegalovirus (CMV) infection has a prevalence in all lung transplant patients and can confer significant morbidity and mortality owing to chronic lung allograft dysfunction and CMV pneumonitis. Most, if not all, lung transplant program postoperative regimens include CMV antiviral prophylaxis …”
“The parent of a seven-month-old female enrollee has requested for Synagis vaccine for treatment of the enrollee’s prematurity and respiratory distress due to transient tachypnea of newborn. Findings: The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from RSV disease in infants born at 32-35 weeks gestation, up to 12 months …”
“The parent of a 7-week-old male enrollee has requested Synagis therapy for Respiratory Syncytial Virus (RSV) prevention. Findings: The physician reviewer found that although this patient does not meet all of the criteria as set forth in the AAP guidelines, he is at risk for significant morbidity and even mortality from RSV disease by virtue of his gestational age, gender, …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Pemgarda. Recent studies have shown that selected immunocompromised patients expected to have suboptimal immune response to vaccination, such as those with active hematologic malignancy, recent stem cell transplantation, or a history of solid organ transplantation, are recommended to receive adjunctive pre-exposure prophylaxis with pemivibart to reduce the …”
- 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 Respiratory System overturned?
In 12 California IMR decisions from 2007 to 2025, reviewers overturned 7 (58.3%). In the last five years: 50.0% of 2. 11 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.