Biologics for Skin Disorders: 90.7% of denials overturned
In 107 California IMR decisions from 2006 to 2025, reviewers overturned 97 (90.7%). In the last five years: 93.3% of 89. 103 were medical-necessity disputes, 4 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 9 | 88.9% |
| 2022 | 4 | 100.0% |
| 2023 | 13 | 76.9% |
| 2024 | 11 | 90.9% |
| 2025 | 52 | 98.1% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 53 | 92.5% | 90.7% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 45 | 88.9% | 90.7% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 15 | 73.3% | 90.7% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 11 | 100.0% | 90.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 7 | 71.4% | 90.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 16.7% | 90.7% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 3 | 66.7% | 90.7% |
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 Spevigo 150 mg/mL syringes.The records provided for review document that this patient has a history of pustular psoriasis, acrochordon, and skin neoplasm. The patient has been treated with numerous medications, including clobetasol, dapsone, and acitretin, without substantial improvement in symptoms. However, treatment with Spevigo has been successful …”
“The physician reviewer found that the parent of a patient has requested authorization and coverage for the Nemluvio 30mg/0.49mL pen. In this case, the patient has a diagnosis of moderate-to-severe atopic dermatitis (AD) that is refractory to alternative treatments, including triamcinolone, prednisone, Opzelura, Eucrisa, clobetasol, Adbry, and Dupixent. As such, the requested medication, Nemluvio 30mg/0.49mL pen, is medically necessary for …”
“The physician reviewer found that a patient has requested authorization and coverage for Nemluvio pen. The U.S. Food and Drug Administration approves the use of Nemluvio for the treatment of adults with prurigo nodularis. Results from randomized, double-blind, placebo-controlled, phase 3 trials demonstrate the efficacy of nemolizumab in treating the symptoms of prurigo nodularis. Per the medical records, the patient …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Adbry. Adbry is a U.S. Food and Drug Administration (FDA)-approved treatment for moderate-to-severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies. A recent consensus article of atopic dermatitis experts noted that atopic dermatitis may be considered …”
- 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 Skin Disorders overturned?
In 107 California IMR decisions from 2006 to 2025, reviewers overturned 97 (90.7%). In the last five years: 93.3% of 89. 103 were medical-necessity disputes, 4 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.