Revision Procedures denials: 29.3% overturned by independent reviewers
In 41 California IMR decisions from 2005 to 2023, reviewers overturned the plan 12 times (29.3%). In the last five years: 16.7% of 6. 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 |
|---|---|---|---|
| Morbid Obesity | 11 | 9.1% | — |
| Endocrine/Metabolic | 5 | 40.0% | 0.0% of 3 |
| Post Surgical Comp | 5 | 40.0% | — |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2022 | 2 | 0.0% |
| 2023 | 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). | 13 | 15.4% | 29.3% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 10 | 30.0% | 29.3% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 66.7% | 29.3% |
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 (1) surgery to remove excessive skin from bilateral arms and (2) surgery to remove excessive skin from bilateral thighs. Findings: The physician reviewer found that The submitted documentation supports the medical necessity of a portion of the requested services. According to the American Society of Plastic Surgeons, …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for revision shoulder surgery to reconstruct a grade 5 acromioclavicular (AC) joint separation using a technique that uses a combination of polyester tape (Lockdown) and a distal clavicle hook plate (Synthes). Researchers noted that coracoclavicular ligament reconstruction by autologous plantaris tendon or allogeneic tendon graft combined with hook …”
“The patient has requested authorization and coverage for scar tissue removal surgery. The patient underwent cosmetic breast augmentation surgery years ago and developed an area of depressed scar that pulls on the underlying tissue when she raises her arm. She reports pain when this occurs. Kumar and Elavarasi stated, “Pain is always subjective, and every individual use this word through …”
- 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 Revision Procedures denials overturned?
In 41 California IMR decisions from 2005 to 2023, reviewers overturned the plan 12 times (29.3%). In the last five years: 16.7% of 6.
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.