Hormones for Sym/Sign Ab Find: 83.3% of denials overturned
In 6 California IMR decisions from 2026 to 2026, reviewers overturned 5 (83.3%). In the last five years: 83.3% of 6. 6 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2026 | 6 | 83.3% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that the parent of a patient has requested authorization and coverage for Omnitrope. Medical literature supports growth hormone therapy for children with idiopathic short stature when height is significantly below age‑based norms and no underlying pathology is identified. In this case, the patient’s height was below the third percentile prior to treatment, and both height and …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Myfembree. First-line therapy for chronic pelvic pain and endometriosis typically consists of nonsteroidal anti-inflammatory drugs (NSAIDs), combined hormonal contraceptives, and progestins. Second-line treatments include gonadotropin-releasing hormone (GnRH) receptor agonists with add-back therapy, GnRH receptor antagonists, and danazol. The European Society of Human …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for Omnitrope. Essential diagnostic criteria for idiopathic short stature, according to the U.S. Food and Drug Administration (FDA) and the Pediatric Endocrine Society, include a standing height of a z-score below –2.25 standard deviations (SDs) or below the 1.2nd percentile and the …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Omnitrope. In this case, the patient’s presentation does not meet the criteria of short stature and idiopathic short stature (ISS). The patient is not short plotting at the 5th percentile, and not more than 2.25 standard deviations (SDs) below …”
- 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 Sym/Sign Ab Find overturned?
In 6 California IMR decisions from 2026 to 2026, reviewers overturned 5 (83.3%). In the last five years: 83.3% of 6. 6 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.