Biofeedback denials: 35.0% overturned by independent reviewers
In 80 California IMR decisions from 2002 to 2024, reviewers overturned the plan 28 times (35.0%). In the last five years: 71.4% of 7. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Mental Disorder | 20 | 10.0% | 0.0% of 1 |
| Digestive System/ GI | 19 | 73.7% | 66.7% of 3 |
| GU/ Kidney Disorder | 12 | 33.3% | 100.0% of 2 |
| Orth/Musculoskeletal | 11 | 45.5% | — |
| Autism Spectrum | 7 | 0.0% | — |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2022 | 5 | 80.0% |
| 2024 | 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. | 27 | 37.0% | 35.0% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 14 | 7.1% | 35.0% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 9 | 77.8% | 35.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 0.0% | 35.0% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 5 | 40.0% | 35.0% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 0.0% | 35.0% |
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
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for pelvic floor program consisting of (rectal balloon biofeedback therapy) three times a day for one week, and twice a day for a second week. The records document that this patient presents with pelvic dyssynergia and possible anal fistula. Treatment has included surgery, but the patient reports continued …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for LORETA neurofeedback therapy two to three times per week for six months. The records provided for review document that this patient has a history of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) with problems in memory, concentration, and hyperarousal symptoms due to traumatic cues associated …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for electrostimulation biofeedback physiotherapy (a total of six one-hour sessions). Electrostimulation biofeedback physiotherapy is a pelvic floor rehabilitation technique that is well supported in current medical literature for the treatment of urinary/fecal incontinence, pelvic pain, erectile dysfunction, defecatory disorders, and dyssynergic defecation. These techniques are largely designed to …”
- 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 Biofeedback denials overturned?
In 80 California IMR decisions from 2002 to 2024, reviewers overturned the plan 28 times (35.0%). In the last five years: 71.4% of 7.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.