Biologics for Respiratory System: 85.7% of denials overturned
In 14 California IMR decisions from 2020 to 2025, reviewers overturned 12 (85.7%). In the last five years: 100.0% of 11. 14 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 3 | 100.0% |
| 2023 | 3 | 100.0% |
| 2024 | 2 | 100.0% |
| 2025 | 3 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 100.0% | 85.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 33.3% | 85.7% |
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 a patient has requested authorization and coverage for Dupixent. Per the medical records, the patient has severe, persistent asthma, eosinophilic phenotype, and is on maximal therapy with inhaled corticosteroid (ICS), long-acting beta2 agonist (LABA), long-acting muscarinic agonist (LAMA), and Xolair. Current medical literature supports the use of dupilumab as resulting in significantly lower rates of …”
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Dupixent. Dupilumab blocks the shared receptor component for interleukin (IL)-4 and IL-13, key drivers of type 2 inflammation in asthma. In a study, dupilumab reduced severe asthma exacerbation rates, improved forced expiratory volume in one second and asthma control, and suppressed type 2 inflammatory biomarkers in patients …”
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Dupixent prefilled pen. Dupixent is indicated for this patient who continues to be symptomatic despite triple inhaler therapy treatment and who has evidence of type 2 inflammation with a documented peripheral eosinophil level over 300 cells/microliter. Overall, Dupixent is currently approved as an add-on maintenance treatment in …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fasenra subcutaneous injections. Findings: Based on the available information, treatment of this patient’s eosinophilic-type asthma with anti-interleukin 5 (IL-5) immunotherapy is medically necessary based on his prior history of poorly controlled asthma. Moreover, the patient has demonstrated excellent response to Fasenra therapy that blocks the IL-5 eosinophilic …”
- 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 Respiratory System overturned?
In 14 California IMR decisions from 2020 to 2025, reviewers overturned 12 (85.7%). In the last five years: 100.0% of 11. 14 were medical-necessity disputes.
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.