Hormones for Endocrine/Metabolic: 42.8% of denials overturned
In 547 California IMR decisions from 2002 to 2025, reviewers overturned 234 (42.8%). In the last five years: 50.0% of 112. 512 were medical-necessity disputes, 35 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 19 | 47.4% |
| 2022 | 8 | 50.0% |
| 2023 | 22 | 45.5% |
| 2024 | 25 | 60.0% |
| 2025 | 38 | 47.4% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 71 | 43.7% | 42.8% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 60 | 1.7% | 42.8% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 35 | 40.0% | 42.8% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 21 | 38.1% | 42.8% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 10 | 20.0% | 42.8% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 8 | 50.0% | 42.8% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 6 | 33.3% | 42.8% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 6 | 16.7% | 42.8% |
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: The patient’s parent has requested authorization and coverage for Norditropin Flexpro. Norditropin is safe and effective for the treatment of pediatric growth hormone deficiency (GHD) and idiopathic short stature (ISS). According to the U.S. Food and Drug Administration and the Pediatric Endocrine Society, the essential diagnostic criteria for ISS are …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for the growth hormone therapy medication, Sogroya. The U.S. Food and Drug Administration (FDA) approved Sogroya for the treatment of pediatric growth hormone deficiency. Clinical trials and post-marketing data have demonstrated its efficacy. Furthermore, it was reported that Sogroya is …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for growth hormone therapy. Growth hormone replacement is indicated in patients with documented deficiency, particularly in the setting of hypothalamic-pituitary disease or multiple pituitary hormone deficiencies, where diagnostic criteria may be met without the need for stimulation testing in certain cases. Clinical guidelines and …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient’s parent has requested authorization and coverage for Omnitrope. Omnitrope is a U.S. Food and Drug Administration (FDA)-approved growth hormone therapy indicated for pediatric patients with confirmed growth hormone deficiency or select cases of idiopathic short stature meeting defined diagnostic criteria. Clinical guidelines require objective evidence of impaired growth velocity, …”
- 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 Hormones denials for Endocrine/Metabolic overturned?
In 547 California IMR decisions from 2002 to 2025, reviewers overturned 234 (42.8%). In the last five years: 50.0% of 112. 512 were medical-necessity disputes, 35 experimental/investigational.
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.