Hormones for Immuno Disorders: 25.0% of denials overturned
In 12 California IMR decisions from 2014 to 2025, reviewers overturned 3 (25.0%). In the last five years: 50.0% of 4. 9 were medical-necessity disputes, 3 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 1 | 100.0% |
| 2024 | 2 | 50.0% |
| 2025 | 1 | 0.0% |
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 | 0.0% | 25.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 66.7% | 25.0% |
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 the patient requested authorization and coverage for Acthar GelThe submitted documentation supports the medical necessity of the requested medication. Acthar Gel is a form of adrenocorticotropic hormone (ACTH) therapy delivered as a gel to provide an extended-release of ACTH following injection. Podocyte infolding glomerulopathy (PIG) is a newly recognized condition so there are few medical …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Nutropin AQ Nuspin. According to the guidelines for growth hormone (GH) and insulin-like growth factor-1 (IGF-1) treatment in pediatric patients, GH therapy is recommended for pediatric patients with GH deficiency to normalize adult height and avoid extreme shortness. In this case, …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HP Acthar Vial. Acthar Gel, an adrenocorticotropic hormone (ACTH) analogue, is U.S. Food and Drug Administration approved for treatment of symptomatic sarcoidosis at a recommended dose of 40-80 units intramusculary or subcutaneously every 24-72 hours. Sarcoidosis is a systemic granulomatous disease of unknown etiology. Over the past …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Acthar Gel. In this case, the patient has been treated with Humira, Enbrel, and Inflectra. These are all biologic disease-modifying anti-rheumatic drugs (DMARDS) belonging to the tumor necrosis factor (TNF) inhibitor class of therapy. The patient has uncontrolled rheumatoid arthritis despite treatment …”
- 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 Immuno Disorders overturned?
In 12 California IMR decisions from 2014 to 2025, reviewers overturned 3 (25.0%). In the last five years: 50.0% of 4. 9 were medical-necessity disputes, 3 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.