IVIG Therapy for Blood Related Disord: 14.3% of denials overturned
In 7 California IMR decisions from 2006 to 2025, reviewers overturned 1 (14.3%). In the last five years: 0.0% of 2. 6 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2025 | 2 | 0.0% |
What the findings mention
From recent overturned decisions
“This patient is a 41-year-old female who has idiopathic thrombocytopenia purpura (ITP). She typically has a platelet count of 50,000 to 65,000 and is appropriately not chronically on therapy. The patient is scheduled for an oophorectomy and her surgeon believes she needs a higher platelet count for the surgery. The patient’s provider has submitted a request for preoperative treatment with …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for subcutaneous immune globulin (SCIG). Findings: The physician reviewer found that the humoral immune system evaluation of the patient is incomplete. A review of the medical records reveals that specific IgG titers for streptococcus pneumoniae, diphtheria, and tetanus do not appear to have been completed. The results of …”
- 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 for Blood Related Disord overturned?
In 7 California IMR decisions from 2006 to 2025, reviewers overturned 1 (14.3%). In the last five years: 0.0% of 2. 6 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.