Hormones for Vision: 50.0% of denials overturned
In 6 California IMR decisions from 2019 to 2025, reviewers overturned 3 (50.0%). In the last five years: 66.7% of 3. 5 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 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. | 3 | 0.0% | 50.0% |
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 Nature of Statutory Criteria/Case Summary:The parent of the patient has requested authorization and coverage for Genotropin 12 mg cartridge. The medical records establish that the patient has septo-optic dysplasia with associated central hypothyroidism, central adrenal insufficiency, structural pituitary abnormalities, and documented pituitary hormone deficiency, including low insulin-like growth factor-1 and insulin-like growth factor binding protein-3 …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel subcutaneous injection administered at 80 units every three days. Acthar Gel, which is an adrenocorticotropic hormone (ACTH) analogue, has been used effectively in the treatment of patients with uveitis. Researchers noted that, “Expert consensus suggests RCI [repository corticotropin injection] may …”
“The patient’s parent has requested authorization and coverage for HP Acthar Gel injections, initiated at 80 units weekly and titrated up to 80 units three times a week as tolerated. Crane and colleagues found that adrenocorticotropic hormone (ACTH) can be effective at decreasing or eliminating ocular inflammation, and that adverse effects of ACTH are rare and most likely to be …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Acthar Gel.The records indicate that this patient presents with a history of panuveitis refractory to current treatment. Uveitis is a group of inflammatory diseases that affect the uveal tract and, in this case, a cause of ocular inflammation. A review of current medical …”
- 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 Vision overturned?
In 6 California IMR decisions from 2019 to 2025, reviewers overturned 3 (50.0%). In the last five years: 66.7% of 3. 5 were medical-necessity disputes, 1 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.