Insulin Pump denials: 71.4% overturned by independent reviewers
In 84 California IMR decisions from 2002 to 2025, reviewers overturned the plan 60 times (71.4%). In the last five years: 100.0% of 8. 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 |
|---|---|---|---|
| Endocrine/Metabolic | 83 | 72.3% | 100.0% of 8 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 100.0% |
| 2022 | 2 | 100.0% |
| 2023 | 1 | 100.0% |
| 2025 | 2 | 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. | 16 | 75.0% | 71.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 0.0% | 71.4% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 3 | 33.3% | 71.4% |
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 Omnipod DASH pods. The American Diabetes Association (ADA) recommends that automated insulin delivery (AID) systems be offered to all adults with type 1 diabetes. In this case, given the variability of the patient’s blood glucose and history of severe hypoglycemia, as evidenced by a recent emergency department …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:The parent of a patient has requested authorization and coverage for a Tandem Mobi external ambulatory insulin pump. Continuous subcutaneous insulin infusion therapy is indicated for patients with type 1 diabetes mellitus who require intensive insulin management. Clinical guidelines support the use of insulin pump therapy, particularly when integrated with continuous …”
“The physician reviewer found that The patient has requested authorization and coverage for Tandem X2 insulin pump and accessories. In a study comparing the metabolic control of pediatric patients with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) versus MDI, the authors noted that the patients who were treated with CSII achieved relatively good metabolic control. Another study …”
- 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 Insulin Pump denials overturned?
In 84 California IMR decisions from 2002 to 2025, reviewers overturned the plan 60 times (71.4%). In the last five years: 100.0% of 8.
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.