Ongoing OON Tx denials: 36.8% overturned by independent reviewers
In 57 California IMR decisions from 2002 to 2024, reviewers overturned the plan 21 times (36.8%). In the last five years: 20.0% of 10. 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 |
|---|---|---|---|
| Pediatrics | 9 | 0.0% | 0.0% of 4 |
| CNS/ Neuromusc Dis | 8 | 75.0% | — |
| Cancer | 6 | 50.0% | 100.0% of 1 |
| Digestive System/ GI | 5 | 20.0% | 0.0% of 1 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 25.0% |
| 2022 | 4 | 0.0% |
| 2023 | 1 | 0.0% |
| 2024 | 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. | 15 | 20.0% | 36.8% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 16.7% | 36.8% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 3 | 0.0% | 36.8% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 0.0% | 36.8% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 33.3% | 36.8% |
| Urgent or emergencyThe findings mention urgency. | 3 | 0.0% | 36.8% |
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: The patient has requested authorization and coverage for the insertion of a hepatic artery infusion pump. In a meta-analysis of the comparative effectiveness of hepatic artery based therapies for unresectable colorectal liver metastases, researchers conclude, “Hepatic arterial infusion, radioembolization, and transcatheter arterial chemoembolization are equally effective in patients with unresectable colorectal liver metastases with marginal …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endocrinology services at a tertiary level of care. Polycystic ovarian syndrome (PCOS) is an endocrine disorder that has been associated with infertility, menstrual disorders, insulin resistance, obesity, and cardiovascular problems (Patel). Although data gained in recent years has improved understanding of the pathogenesis, diagnosis, and clinical manifestations, …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary level of care services. As noted in the medical literature, hidradenitis suppurativa can profoundly affect a patient’s quality of life. Severity is based on clinical appearance as well as impact on quality of life. According to the U.S. and Canadian Hidradenitis Suppurativa Foundations, “management is complex …”
- 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 Ongoing OON Tx denials overturned?
In 57 California IMR decisions from 2002 to 2024, reviewers overturned the plan 21 times (36.8%). In the last five years: 20.0% of 10.
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.