Early Discharge denials: 30.8% overturned by independent reviewers
In 26 California IMR decisions from 2005 to 2025, reviewers overturned the plan 8 times (30.8%). In the last five years: 36.4% of 11. 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 |
|---|---|---|---|
| Cancer | 6 | 33.3% | 50.0% of 2 |
| Cardiac/Circ Problem | 5 | 0.0% | 0.0% of 2 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 0.0% |
| 2022 | 4 | 50.0% |
| 2023 | 2 | 50.0% |
| 2024 | 2 | 0.0% |
| 2025 | 1 | 100.0% |
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). | 5 | 0.0% | 30.8% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 0.0% | 30.8% |
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 Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for the inpatient stay. In this case, the patient underwent a surgical shunt exploration, and a valve dysfunction was determined. The patient’s valve was changed to a programmable valve, which was then adjusted over the postoperative period until the correct setting was found based on the …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospital services.Based upon the submitted documentation, the inpatient hospital services at issue were medically necessary to treat the patient’s medical condition. The patient presented with a large right lung cancer requiring major chest surgery with the removal of the entire right lung. Like …”
“The physician reviewer found that The patient has requested reimbursement for inpatient hospital services. Burst fractures of the spine result from high energy trauma that results in comminution and breaking of the vertebral body into multiple pieces. This type of injury may be associated with neurological complications due to compression of nerves by bone with loss of sensation, lower extremity …”
- 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 Early Discharge denials overturned?
In 26 California IMR decisions from 2005 to 2025, reviewers overturned the plan 8 times (30.8%). In the last five years: 36.4% of 11.
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.