# Apellica Appeal Outcomes Library: Methodology (California IMR)

Canonical: https://apellica.com/appeal-outcomes. Aggregates and tags CC BY 4.0. Corrections: editorial@apellica.com.

## Source
California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data): https://data.chhs.ca.gov/dataset/independent-medical-review-imr-determinations-trend. Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Loaded 42,710 decisions (2001–2026); 22,431 overturned. Last download: Fri Sep 11 2026 18:04:09 GMT+0000 (Coordinated Universal Time).

## What was done
1. Downloaded the full CSV monthly; upserted by ReferenceID.
2. "Overturned" = Determination starts with "Overturned Decision of Health Plan"; "Upheld" = starts with "Upheld".
3. Grouped by DMHC's TreatmentSubCategory and DiagnosisCategory (slugified); the catch-all "Other" is excluded from rankings; pages exist for groups with at least 5 decisions and are indexed at 20 or more.
4. Argument tags are regular-expression matches on the Findings text: prior_therapies_failed (Prior therapies failed); contraindicated (Alternatives contraindicated); guidelines_support (Guidelines or criteria cited); literature (Published evidence cited); fda_label (FDA approval or off-label use discussed); no_alternative (No reasonable alternative); records_lacking (Records did not support); experimental (Experimental or investigational); step_therapy (Step therapy or fail-first); urgent (Urgent or emergency). They describe what the findings mention, not causation.
5. Excerpts are the first 60 words of the reviewer's findings from the most recent overturned decisions in the group, attributed by ReferenceID and year. Full decisions are not republished.
6. Nothing is estimated or adjusted.

## Caveats (shown on every page)
- 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.