Emergency for Cardiac/Circ Problem: 83.3% of denials overturned
In 6 California IMR decisions from 2018 to 2025, reviewers overturned 5 (83.3%). In the last five years: 75.0% of 4. 4 were medical-necessity disputes, 2 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2024 | 2 | 100.0% |
| 2025 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 4 | 100.0% | 83.3% |
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
“Nature of Statutory Criteria/Case Summary: A patient’s representative has requested reimbursement for air ambulance services. The records indicate that this patient was transported via air ambulance. The patient was accepted for continued care and follow-up treatment for diagnoses including advanced-stage lung cancer, septic shock, congestive heart failure, and bronchospasm. Patients with septic shock encounter a significantly increased risk of morbidity, …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance service. Researchers explain that basilar artery thrombosis is a devastating form of stroke with high morbidity and mortality, with mortality rates greater than 85% that drop to 40% with recanalization. While survival after stroke depends initially on the acute phase of specialist hospital care, optimal recovery requires …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for air ambulance service. Acute ischemic stroke is a medical emergency caused by decreased blood flow to the brain resulting in damage to brain cells. Symptoms of stroke can include sudden-onset numbness or weakness in an arm or leg, facial droop, difficulty speaking …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance services. Sardaro and colleagues describe epithelioid hemangioendothelioma as a rare vascular neoplasm whose etiology is still a dilemma. Jue and colleagues note that telemedicine may allow a surgical oncologist to manage and treat complex cancer diseases. In this case, while the patient has a rare diagnosis, the …”
- 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 denials for Cardiac/Circ Problem overturned?
In 6 California IMR decisions from 2018 to 2025, reviewers overturned 5 (83.3%). In the last five years: 75.0% of 4. 4 were medical-necessity disputes, 2 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.