IVIG Therapy for Digestive System/ GI: 71.4% of denials overturned
In 7 California IMR decisions from 2003 to 2025, reviewers overturned 5 (71.4%). In the last five years: 100.0% of 3. 7 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 2 | 100.0% |
| 2025 | 1 | 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. | 4 | 75.0% | 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
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Remicade 10 mg/kg every four weeks. The records document that this patient has a history of ulcerative colitis. The patient has partially responded to treatment with Remicade and methotrexate. The patient’s Remicade dosage has been increased from 10 mg every eight weeks to 10 mg every six …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parents of the patient requested authorization and coverage for Infliximab-Dyyb; Biosimilar; (Inflectra®); 10mg (200mg 0, 2, 6 and then every 8 weeks).Very early onset inflammatory bowel disease of both Crohn's disease and ulcerative colitis is a very challenging disease to address for pediatric patients. Due to the severity of …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for vedolizumab (Entyvio) 300 mg intravenous (IV) infusion. The request for Entyvio is supported as medically necessary for the treatment of this patient’s Crohn’s disease. Entyvio is recommended as safe and effective by guidelines for the induction of remission in patients with Crohn’s disease. Alternative medications, are not …”
And one the reviewer upheld
“The patient has requested authorization and coverage for Simponi. The U.S. Food and Drug Administration (FDA) approved Simponi for the treatment of patients with ulcerative colitis. This patient has failed three other anti-tumor necrosis factor alternatives for treatment of his Crohn’s disease. Other treatment was initially effective, until the patient developed antibodies. Given the findings in current medical literature, the …”
- 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 Digestive System/ GI overturned?
In 7 California IMR decisions from 2003 to 2025, reviewers overturned 5 (71.4%). In the last five years: 100.0% of 3. 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.