Injection Admin Drugs denials: 86.2% overturned by independent reviewers
In 29 California IMR decisions from 2026 to 2026, reviewers overturned the plan 25 times (86.2%). In the last five years: 86.2% of 29. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Digest System | 7 | 100.0% | 100.0% of 7 |
| Musculoskeletal | 7 | 71.4% | 71.4% of 7 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2026 | 29 | 86.2% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 10 | 80.0% | 86.2% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 5 | 100.0% | 86.2% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 75.0% | 86.2% |
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 the medication regimen, Humira and Stelara when used in combination. Per the medical records, the patient has severe disease complicated by fistula and has failed multiple other therapeutic medication classes used in the management of Crohn’s disease, and is already on dose‑escalated Stelara. With the addition of …”
“The physician reviewer found that a patient has requested authorization and coverage for Monovisc injection for knee osteoarthritis. According to the medical literature, viscosupplementation is only recommended for patients with osteoarthritis of the knees with a history of lasting benefit from prior injections, and in patients who have tried and failed all other options and whose remaining options are limited. …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Entyvio intravenous (IV) every eight weeks, for a year. Entyvio is effective for the treatment of moderate-to-severe ulcerative colitis. The American Gastroenterological Association guidelines and American College of Gastroenterology guidelines support Entyvio as primary therapy for moderate-to-severe ulcerative colitis. Entyvio has also …”
- 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 Injection Admin Drugs denials overturned?
In 29 California IMR decisions from 2026 to 2026, reviewers overturned the plan 25 times (86.2%). In the last five years: 86.2% of 29.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.