Hernia Repair for Digestive System/ GI: 40.0% of denials overturned
In 30 California IMR decisions from 2002 to 2025, reviewers overturned 12 (40.0%). In the last five years: 50.0% of 4. 24 were medical-necessity disputes, 5 experimental/investigational, 1 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 100.0% |
| 2024 | 1 | 0.0% |
| 2025 | 1 | 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. | 8 | 50.0% | 40.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 0.0% | 40.0% |
| Urgent or emergencyThe findings mention urgency. | 4 | 50.0% | 40.0% |
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
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for surgical hiatal hernia repair. The submitted documentation supports the medical necessity of the requested surgical hiatal hernia repair. The records indicate that the patient had a sliding hiatal hernia on an esophagogastroduodenoscopy completed previously. Although the hiatal hernia was not seen on a subsequent endoscopy, a sliding …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for robotic takedown of the prior fundoplication, redo revision hiatal hernia repair, and conversion to gastrojejunostomy with Roux-en-Y reconstruction. In this case, the patient has an elevated body mass index (BMI) and a diagnosis of gastroesophageal reflux disease (GERD). Medical literature report that the minimally invasive Roux-en-Y bypass …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hernia surgery on or before 12/11/20. Ramanan and colleagues note that observation is an acceptable management strategy for asymptomatic and minimally symptomatic inguinal hernias. However, in this case, the patient has a symptomatic inguinal hernia, which he reports as increasingly painful and interfering with activities of daily …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hernia repair surgery. In this case, the patient’s hernia measures 1.9 cm. The records do not demonstrate that the hernia is incarcerated or strangulated. The requested surgery is not indicated for a patient with a hernia less than 5 cm that is neither incarcerated nor strangulated. All …”
- 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 Hernia Repair denials for Digestive System/ GI overturned?
In 30 California IMR decisions from 2002 to 2025, reviewers overturned 12 (40.0%). In the last five years: 50.0% of 4. 24 were medical-necessity disputes, 5 experimental/investigational, 1 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.