Digestion/GI Rx for Infectious Disease: 50.0% of denials overturned
In 6 California IMR decisions from 2019 to 2025, reviewers overturned 3 (50.0%). In the last five years: 40.0% of 5. 6 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2022 | 2 | 0.0% |
| 2025 | 2 | 50.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Vowst capsule. According to the U.S. Food and Drug Administration (FDA) approval for Vowst, Vowst is indicated to prevent the recurrence of Clostridioides difficile infection (C. diff) in patients 18 years of age and older following antibacterial treatment. This patient has required …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg 28 tablets. In reviewing studies of patients treated with doses of rifaximin ranging from 600 mg to 1600 mg daily for a duration ranging from five to 28 days, Gatta and Scarpignato noted that rifaximin treatment appeared effective and safe for the treatment of …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Pylera capsules 1 box x 10 days. The patient has H. pylori infection found on endoscopy without a subsequent complete treatment. According to the American College of Gastroenterology (ACG) guidelines for the treatment of H. pylori, therapy is recommended in all positive patients, and Pylera is the …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vowst. The two most common definitions of recurrent Clostridioides difficile (C. difficile) infection are the recurrence of diarrhea within approximately 30 days of a previous C. difficile infection with a positive C. difficile toxin test, and a total of three or more …”
- 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 Digestion/GI Rx denials for Infectious Disease overturned?
In 6 California IMR decisions from 2019 to 2025, reviewers overturned 3 (50.0%). In the last five years: 40.0% of 5. 6 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.