Cardiac Rx for Cardiac/Circ Problem: 39.8% of denials overturned
In 113 California IMR decisions from 2003 to 2025, reviewers overturned 45 (39.8%). In the last five years: 40.6% of 32. 107 were medical-necessity disputes, 6 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 50.0% |
| 2022 | 7 | 42.9% |
| 2023 | 9 | 33.3% |
| 2024 | 8 | 37.5% |
| 2025 | 4 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 22 | 0.0% | 39.8% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 20 | 55.0% | 39.8% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 13 | 38.5% | 39.8% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 6 | 16.7% | 39.8% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 5 | 40.0% | 39.8% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 50.0% | 39.8% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 33.3% | 39.8% |
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’s parent has requested reimbursement and prospective authorization and coverage for ivabradine.The records provided for review indicate that this patient meets the diagnostic criteria for inappropriate sinus tachycardia (IST), including a resting heart rate consistently above a persistently elevated rate, symptoms of palpitations, dizziness, intolerance of upright posture, and syncope, and no secondary cause …”
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Entresto. The current expert guidelines indicate that an angiotensin receptor-neprilysin inhibitor (ARNI) is preferred for patients with New York Heart Association (NYHA) class II or greater symptoms and left ventricular ejection fraction of less than 40% (Heidenreich, et al.). In this case, the patient has a history …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Nexletol. Nexletol (bempedoic acid) is a U.S. Food and Drug Administration (FDA)-approved LDL-lowering therapy that works via a different mechanism than statins. A trial demonstrated that bempedoic acid has an efficacy comparable to statins in reducing LDL levels. Nexletol is a reasonable …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for Nexlizet tablets. In this case, the patient has been diagnosed with peripheral vascular disease (PVD) and hyperlipidemia. The records provided for review reveal that the patient was being treated with Nexlizet, Repatha, atorvastatin, and Vascepa. At a low-density lipoprotein cholesterol (LDL-C) level of a value well below …”
- 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 Cardiac Rx denials for Cardiac/Circ Problem overturned?
In 113 California IMR decisions from 2003 to 2025, reviewers overturned 45 (39.8%). In the last five years: 40.6% of 32. 107 were medical-necessity disputes, 6 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.