Emergency Room for Respiratory System: 38.1% of denials overturned
In 42 California IMR decisions from 2008 to 2025, reviewers overturned 16 (38.1%). In the last five years: 50.0% of 2. , 42 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 1 | 0.0% |
| 2025 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 42 | 38.1% | 38.1% |
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 reimbursement for medical services. In this case, the patient did not receive emergency medical services. However, the patient did receive urgent medical services. These services were necessary to prevent serious deterioration of the health of the patient, resulting from an unforeseen illness, injury, or complication of …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services on an emergent basis or urgent basis. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation …”
“The parent of a 10-year-old female enrollee requested emergency services on an emergent basis for medical treatment of the enrollee’s medical condition. Findings: The physician reviewer found that a prudent layperson would have sought immediate medical attention on the date of service in question. Although the patient was afebrile at the time of presentation to the ED, the patient’s parent …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for inpatient care services. Many pediatric patients experience an episode or recurrent episodes of wheezing in the first six years of life, often linked to a viral respiratory infection. The records indicate that this pediatric patient was recently enrolled in daycare and diagnosed with viral bronchiolitis several weeks prior …”
- 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 Emergency Room denials for Respiratory System overturned?
In 42 California IMR decisions from 2008 to 2025, reviewers overturned 16 (38.1%). In the last five years: 50.0% of 2. , 42 urgent care.
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.