Hormones for GU/ Kidney Disorder: 55.7% of denials overturned
In 61 California IMR decisions from 2003 to 2025, reviewers overturned 34 (55.7%). In the last five years: 65.6% of 32. 55 were medical-necessity disputes, 6 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 33.3% |
| 2022 | 11 | 72.7% |
| 2023 | 4 | 75.0% |
| 2024 | 8 | 75.0% |
| 2025 | 6 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 33 | 57.6% | 55.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 10 | 50.0% | 55.7% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 10 | 100.0% | 55.7% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 7 | 42.9% | 55.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 0.0% | 55.7% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 33.3% | 55.7% |
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 a patient has requested authorization and coverage for Tarpeyo therapy. While clinical trials have focused on patients with an eGFR equaling 35 mL/min/1.73 m², Tarpeyo's U.S. Food and Drug Administration (FDA) approval does not contraindicate its use for those with lower estimated glomerular filtration rate (eGFR) values. Further, a review of medical literature reveals that …”
“The physician reviewer found that a patient has requested authorization and coverage for Acthar. Acthar may meet an important treatment need in patients with treatment-resistant nephrotic syndrome in response to first-line therapies, in patients unable to tolerate first-line therapies, and in patients with advanced disease. Per the medical records, the patient has a diagnosis of nephrotic syndrome, with complications from …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Tarpeyo. In this case, the record establishes that the patient has a diagnosis of IgAN and a 24-hour urine protein of 1,689 mg/day that has persisted while on angiotensin receptor blocker (ARB) therapy and Farxiga. Thus, the requested medication, Tarpeyo, is medically …”
And one the reviewer upheld
“The physician reviewer found that the enrollee has requested authorization and coverage for testosterone replacement therapy. Several issues require further evaluation prior to the safe administration of testosterone. Guidelines recommend distinguishing between primary and central hypogonadism through measurement of luteinizing hormone and follicle‑stimulating hormone levels, which is not documented in this case. Another consideration is whether the enrollee has functional …”
- 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 GU/ Kidney Disorder overturned?
In 61 California IMR decisions from 2003 to 2025, reviewers overturned 34 (55.7%). In the last five years: 65.6% of 32. 55 were medical-necessity disputes, 6 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.