Fibroid Removal denials: 52.2% overturned by independent reviewers
In 23 California IMR decisions from 2002 to 2022, reviewers overturned the plan 12 times (52.2%). In the last five years: 100.0% of 2. 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 |
|---|---|---|---|
| OB-GYN/ Pregnancy | 14 | 42.9% | — |
| GU/ Kidney Disorder | 7 | 71.4% | 100.0% of 2 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 2 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 33.3% | 52.2% |
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: The patient has requested authorization and coverage for surgical removal of fibroids (laparoscopic myomectomy). The records document that this patient has a history of heavy bleeding and pelvic pain in the setting of a fibroid uterus. The patient has requested treatment with a uterine sparing procedure. On review of the peer-reviewed medical literature and current …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic surgical radiofrequency ablation (RFA) of uterine fibroids. Uterine fibroids are the most common benign tumors of the female reproductive tract causing symptoms such as heavy bleeding, bulk symptoms, pain, and increased urinary frequency. Some patients prefer minimally invasive approaches for fibroid treatment with desire for uterine …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hysteroscopy myomectomy procedure under a tertiary level of care. Vilos and colleagues note that for symptomatic fibroids causing menstrual abnormalities such as heavy, irregular, and prolonged uterine bleeding, hysterectomy is a definitive solution. The authors further stated that hysteroscopic myomectomy should be considered first-line conservative surgical …”
- 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 Fibroid Removal denials overturned?
In 23 California IMR decisions from 2002 to 2022, reviewers overturned the plan 12 times (52.2%). In the last five years: 100.0% of 2.
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.