Elect Bone Stim denials: 33.9% overturned by independent reviewers
In 56 California IMR decisions from 2002 to 2025, reviewers overturned the plan 19 times (33.9%). In the last five years: 41.7% of 12. 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 |
|---|---|---|---|
| Orth/Musculoskeletal | 42 | 31.0% | 12.5% of 8 |
| Cardiac/Circ Problem | 5 | 40.0% | 100.0% of 1 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 6 | 50.0% |
| 2022 | 3 | 33.3% |
| 2023 | 1 | 0.0% |
| 2025 | 2 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 19 | 42.1% | 33.9% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 0.0% | 33.9% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 4 | 50.0% | 33.9% |
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:A patient has requested authorization and coverage for a bone growth stimulator. Bone growth stimulation is indicated in patients at high risk for nonunion or impaired fusion, particularly following revision spinal surgery. In this case, the patient underwent reoperation with removal of prior cervical implants, which is associated with disruption of …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 SLSA functional electrical stimulator (FES). In this case, the patient has a diagnosis of locked-in state. Emphasizing the need for significant multidisciplinary rehabilitation, Researchers report that multimodal treatments that are frequent and sensory can provide significant improvement for patients with locked-in syndrome. The authors further note …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an osteogenesis stimulator.A review of the literature pertaining to electrical stimulation for osteogenesis of a pars interarticularis defect reveals this to be a viable option. electrical stimulation has long been used for healing of fracture non-unions. a computational model showed that electrical stimulation facilitated bone restoration by …”
- 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 Elect Bone Stim denials overturned?
In 56 California IMR decisions from 2002 to 2025, reviewers overturned the plan 19 times (33.9%). In the last five years: 41.7% of 12.
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.