Birth Control denials: 45.0% overturned by independent reviewers
In 20 California IMR decisions from 2003 to 2022, reviewers overturned the plan 9 times (45.0%). In the last five years: 100.0% of 4. 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 |
|---|---|---|---|
| OB-GYN/ Pregnancy | 11 | 18.2% | — |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 100.0% |
| 2022 | 1 | 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. | 5 | 40.0% | 45.0% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 3 | 33.3% | 45.0% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Orilissa 200 mg tablets received monthly. The records document that this patient has a history of symptomatic uterine fibroids, with a primary presenting symptom of dysmenorrhea or severe pain with menses. As noted in the medical literature, several treatment …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Annovera birth control ring.Combined (estrogen-progestin) hormonal contraception is highly effective and available in multiple forms and formulations, including as a vaginal ring. In the United States, there are two commonly available combined hormonal contraceptive rings, the etonogestrel/ethinyl estradiol ring and the segesterone acetate/ethinyl estradiol ring. This second …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name LoSeasonique tablets. LoSeasonique 20 ug with three-month dosing does not have a comparable contraceptive medication in the same class. In this case, the provider noted that the patient has been treated with medications similar to LoSeasonique with a lack of efficacy or intolerable side effects. …”
- 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 Birth Control denials overturned?
In 20 California IMR decisions from 2003 to 2022, reviewers overturned the plan 9 times (45.0%). In the last five years: 100.0% of 4.
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.