Req 2nd Opin/OON denials: 46.4% overturned by independent reviewers
In 28 California IMR decisions from 2004 to 2021, reviewers overturned the plan 13 times (46.4%). In the last five years: 100.0% of 1. 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 |
|---|---|---|---|
| Cancer | 6 | 66.7% | — |
| Orth/Musculoskeletal | 6 | 50.0% | — |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 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 | 50.0% | 46.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 0.0% | 46.4% |
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: The patient has requested authorization and coverage for tertiary level vascular surgery second opinion consultation. The records provided for review document that this patient has unique characteristics that warrant evaluation and treatment at a higher level of care. Specifically, the patient’s body mass index (BMI) supports a finding of morbid obesity and the duplex results …”
“Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for a consult regarding a bilateral mastectomy and male chest reconstruction, and for a bilateral mastectomy and/or male chest reconstruction. The enrollee is a male who was treated by a psychiatrist for gender dysphoria, anxiety, and panic disorder. His secondary sex characteristics cause him to feel …”
“The patient has requested authorization and coverage for Yescarta therapy (CAR-T immunotherapy). Prior studies of autologous or allogeneic stem cell transplantation for relapsed DLBCL DHL demonstrate poor health outcomes and no significant clinical benefit following induction chemotherapy (Herrera, et al.; Landsburg, et al.). In a study of outcomes for patients with DHL who achieved a first complete remission following induction …”
- 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 Req 2nd Opin/OON denials overturned?
In 28 California IMR decisions from 2004 to 2021, reviewers overturned the plan 13 times (46.4%). In the last five years: 100.0% of 1.
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.