Biologics for Blood Related Disord: 57.1% of denials overturned
In 7 California IMR decisions from 2019 to 2025, reviewers overturned 4 (57.1%). In the last five years: 60.0% of 5. 5 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 2 | 50.0% |
| 2024 | 1 | 100.0% |
| 2025 | 2 | 50.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Nplate and/or Feraheme.Agents that stimulate platelet production, such as Nplate, are approved by the U.S. Food and Drug Administration for indications such as immune thrombocytopenic purpura. In this case, the patient has a history of immune thrombocytopenia purpura. Based on the records, …”
“Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Besremi. In this case, a review of the record establishes that the patient has a history of polycythemia vera with a positive JAK2 V617F mutation. The patient was treated with aspirin 81mg daily and hydroxyurea for thrombosis prevention. The patient’s most recent blood testing results revealed a high …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Besremi Solution Prefilled Syringe. Essential thrombocythemia is a myeloproliferative disorder caused by specific mutations in the hematopoietic stem cells. Essential thrombocythemia manifests as a high platelet count, which predisposes patients to abnormal clotting. As noted in the medical literature, there is a large overlap between essential thrombocythemia …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for rituximab. Idiopathic thrombocytopenia (ITP) is managed based on platelet count and the presence of bleeding symptoms. Treatment to increase platelet count is generally indicated in patients with significantly low platelet levels or active bleeding. In this case, the patient has a history …”
- 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 Biologics denials for Blood Related Disord overturned?
In 7 California IMR decisions from 2019 to 2025, reviewers overturned 4 (57.1%). In the last five years: 60.0% of 5. 5 were medical-necessity disputes, 2 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.