IVIG Therapy denials: 49.1% overturned by independent reviewers
In 385 California IMR decisions from 2002 to 2026, reviewers overturned the plan 189 times (49.1%). In the last five years: 62.3% of 151. 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 |
|---|---|---|---|
| Immuno Disorders | 158 | 47.5% | 62.3% of 69 |
| CNS/ Neuromusc Dis | 134 | 55.2% | 62.0% of 50 |
| OB-GYN/ Pregnancy | 15 | 6.7% | — |
| Infectious Disease | 11 | 18.2% | 25.0% of 4 |
| Orth/Musculoskeletal | 10 | 50.0% | 40.0% of 5 |
| Cardiac/Circ Problem | 9 | 55.6% | 80.0% of 5 |
| Digestive System/ GI | 7 | 71.4% | 100.0% of 3 |
| Blood Related Disord | 7 | 14.3% | 0.0% of 2 |
| Genetic Diseases | 5 | 40.0% | 33.3% of 3 |
| Skin Disorders | 5 | 80.0% | 100.0% of 3 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 30 | 66.7% |
| 2022 | 35 | 65.7% |
| 2023 | 16 | 43.8% |
| 2024 | 34 | 50.0% |
| 2025 | 34 | 73.5% |
| 2026 | 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. | 156 | 53.8% | 49.1% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 59 | 5.1% | 49.1% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 56 | 64.3% | 49.1% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 45 | 73.3% | 49.1% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 30 | 30.0% | 49.1% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 21 | 14.3% | 49.1% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 14 | 50.0% | 49.1% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 10 | 50.0% | 49.1% |
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: A patient has requested authorization and coverage for intravenous immune globulin (IVIG) infusion, Gammagard. Based on the records, this patient has been diagnosed with necrotizing autoimmune myopathy and has been receiving monthly IVIG in combination with methotrexate and low-dose prednisone. Clinical documentation demonstrates normalization and stabilization of the patient’s creatine …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for intravenous immune globulin therapy, Gammaplex. The treating provider requested intravenous immune globulin because of refractory symptoms, positive antibody findings, and limited alternative treatment options.Current medical literature supports intravenous immune globulin as an anti-inflammatory and immunomodulatory therapy for a variety of autoimmune neurologic …”
“The physician reviewer found that a patient has requested authorization and coverage for immune globulin (Cuvitru). The decision to initiate or continue immunoglobulin replacement therapy should be made based on clinical and laboratory findings supportive of a diagnosis of a clinically significant antibody production defect. This patient’s clinical history (recurrent upper respiratory infections) and recent laboratory evaluation (incomplete response to …”
- 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 IVIG Therapy denials overturned?
In 385 California IMR decisions from 2002 to 2026, reviewers overturned the plan 189 times (49.1%). In the last five years: 62.3% of 151.
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.