Cardiac Rx for Endocrine/Metabolic: 36.7% of denials overturned
In 49 California IMR decisions from 2009 to 2025, reviewers overturned 18 (36.7%). In the last five years: 34.3% of 35. 47 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 9 | 77.8% |
| 2022 | 5 | 20.0% |
| 2023 | 2 | 100.0% |
| 2024 | 10 | 20.0% |
| 2025 | 9 | 0.0% |
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). | 14 | 0.0% | 36.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 12 | 0.0% | 36.7% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 7 | 42.9% | 36.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 75.0% | 36.7% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 3 | 33.3% | 36.7% |
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 Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Leqvio. In an open-label extension study of preceding Phase 2 and Phase 3 placebo-controlled and open-label extension trials, researchers concluded that inclisiran demonstrated sustained and substantial low-density lipoprotein (LDL) cholesterol lowering with a favorable long-term safety and tolerability profile. In this case, …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Repatha Sureclick auto-injector. According to the American College of Cardiology (ACC), the PCSK9 inhibitors evolocumab (Repatha) and alirocumab (Praluent) may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in high-risk patients with atherosclerotic …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha Sureclick solution auto-injector. Researchers found that Repatha should be considered as a treatment option for patients with atherosclerotic cardiovascular disease whose goals of therapy have not been achieved on maximally tolerated statins and ezetimibe. In this case, the patient has a …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for Repatha. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol. An elevated lipoprotein(a) is considered a risk enhancing factor and supports more aggressive …”
- 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 Endocrine/Metabolic overturned?
In 49 California IMR decisions from 2009 to 2025, reviewers overturned 18 (36.7%). In the last five years: 34.3% of 35. 47 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.