Asthma Rx for Respiratory System: 67.4% of denials overturned
In 46 California IMR decisions from 2019 to 2025, reviewers overturned 31 (67.4%). In the last five years: 69.7% of 33. 45 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 8 | 62.5% |
| 2022 | 3 | 33.3% |
| 2023 | 7 | 85.7% |
| 2024 | 10 | 100.0% |
| 2025 | 5 | 20.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 22 | 77.3% | 67.4% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 10 | 80.0% | 67.4% |
| Urgent or emergencyThe findings mention urgency. | 6 | 50.0% | 67.4% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 66.7% | 67.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 67.4% |
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
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Dupixent. Dupixent is a fully humanized IgG4 monoclonal antibody, inhibiting IL-4 and IL-13 signaling, which are the main cytokines involved in type 2 inflammatory diseases. Current indications include atopic dermatitis, uncontrolled asthma, and chronic rhinosinusitis with nasal polyposis. Overall, clinical trials have indicated that patients who received …”
“The physician reviewer found that the patient has a history of moderate persistent asthma and moderate atopic dermatitis. The patient is requested authorization and coverage for Dupixent. The patient presents with inadequately controlled asthma on standard therapies with an allergic phenotype based on concurrent atopic dermatitis. A review of the record reveals that the treatment with Dupixent is medically appropriate …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient with a diagnosis of severe persistent asthma has requested authorization and coverage for Nucala. In this case, the patient has evidence of severe persistent eosinophilic asthma based on a high baseline eosinophil count and her requirement for multiple bursts of prednisone. The patient has attempted treatment with Symbicort, …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Tezspire. Tezspire is indicated for add-on maintenance treatment of patients aged 12 years and older with severe asthma. This patient is over the age of 12, but the severity of the patient’s asthma is unclear. It is acknowledged that the patient is …”
- 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 Asthma Rx denials for Respiratory System overturned?
In 46 California IMR decisions from 2019 to 2025, reviewers overturned 31 (67.4%). In the last five years: 69.7% of 33. 45 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.