Glucagon-Like Peptide-1 (GLP) for Cardiac/Circ Problem: 50.0% of denials overturned
In 8 California IMR decisions from 2025 to 2025, reviewers overturned 4 (50.0%). In the last five years: 50.0% of 8. 8 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2025 | 8 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 33.3% | 50.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 100.0% | 50.0% |
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 Wegovy. Continuation of Wegovy is indicated for this patient who presents with overweight and significant cardiometabolic risk factors, including prediabetes, hypertension, and hyperlipidemia. The patient has demonstrated substantial weight loss and improved metabolic profile over one year of therapy. Based on the …”
“The physician reviewer found that a patient has requested authorization and coverage for Wegovy. In this case, the record establishes that the patient is obese with a body mass index a BMI in the obese range with the comorbidity of hypertension. Further, the patient has a familial history of heart disease. As such, Wegovy is medically necessary for the treatment …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for Wegovy. Wegovy is a U.S. Food and Drug Administration (FDA)-approved medication for chronic weight management in patients with obesity or those who are overweight with weight-related comorbidities, in conjunction with lifestyle modifications. Medical literature supports the use of pharmacologic therapy for weight management …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Wegovy. Per the medical records, the patient has arteriosclerotic coronary artery disease, with an elevated coronary artery calcium score (CACS) of 84.83, and a body mass index (BMI) of 20.31 kg/m². The U.S. Food and Drug Administration (FDA) and Endocrine Society clinical …”
- 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 Glucagon-Like Peptide-1 (GLP) denials for Cardiac/Circ Problem overturned?
In 8 California IMR decisions from 2025 to 2025, reviewers overturned 4 (50.0%). In the last five years: 50.0% of 8. 8 were medical-necessity disputes.
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.