Injection Admin Drugs for Digest System: 100.0% of denials overturned
In 7 California IMR decisions from 2026 to 2026, reviewers overturned 7 (100.0%). In the last five years: 100.0% of 7. 7 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2026 | 7 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 100.0% | 100.0% |
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 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 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 …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Botox shots. In this case, the patient has a history of acute and chronic anal fissure. The record establishes that the patient has failed medical management. The patient has persistent symptoms of anal fissure despite this medical management. As such, the requested …”
- 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 for Digest System overturned?
In 7 California IMR decisions from 2026 to 2026, reviewers overturned 7 (100.0%). In the last five years: 100.0% of 7. 7 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.