Oxygen for Respiratory System: 17.9% of denials overturned
In 28 California IMR decisions from 2002 to 2025, reviewers overturned 5 (17.9%). In the last five years: 33.3% of 3. 28 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 1 | 100.0% |
| 2025 | 2 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 0.0% | 17.9% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 25.0% | 17.9% |
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 requested authorization and coverage for a portable oxygen system in order to perform daily living activities outside the home for the treatment of chronic obstructive pulmonary disease.Ambulatory oxygen therapy refers to oxygen delivered during exercise or other activities of daily living. In order to determine if a patient requires home ambulatory oxygen therapy, …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the oxygen concentrator, oxygen supplies and portable gaseous oxygen system provided for treatment of the enrollee’s chronic obstructive pulmonary disease (COPD). Findings: The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) coverage requirement for home oxygen and portable oxygen requires an oxygen saturation of room …”
“A 62-year-old male enrollee has requested a portable air concentrator (backpack) for treatment of his chronic obstructive pulmonary disease (COPD). Findings: The physician reviewer found that the submitted documentation establishes the medical necessity of the requested equipment. This patient requires continuous oxygen therapy. His room air oxygen saturation is less than 88% and he currently uses three liters per minute …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a portable oxygen concentrator. Venous blood gases should not be used as an indication for portable oxygen concentrators. Furthermore, the subsequent chest computed tomography (CT) and pulmonary function tests argue against many potential causes of true hypoxemia in this patient. While carbon monoxide levels can cause a …”
- 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 Oxygen denials for Respiratory System overturned?
In 28 California IMR decisions from 2002 to 2025, reviewers overturned 5 (17.9%). In the last five years: 33.3% of 3. 28 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.