SCP Consult Refer denials: 59.2% overturned by independent reviewers
In 348 California IMR decisions from 2001 to 2025, reviewers overturned the plan 206 times (59.2%). In the last five years: 66.2% of 68. 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 |
|---|---|---|---|
| Orth/Musculoskeletal | 64 | 57.8% | 63.6% of 11 |
| Cardiac/Circ Problem | 38 | 65.8% | 76.9% of 13 |
| CNS/ Neuromusc Dis | 33 | 48.5% | 100.0% of 5 |
| Skin Disorders | 31 | 74.2% | 75.0% of 4 |
| Morbid Obesity | 27 | 66.7% | — |
| GU/ Kidney Disorder | 18 | 66.7% | 62.5% of 8 |
| Digestive System/ GI | 17 | 70.6% | 80.0% of 5 |
| Endocrine/Metabolic | 16 | 43.8% | 50.0% of 4 |
| Cancer | 14 | 78.6% | 66.7% of 3 |
| Mental Disorder | 12 | 33.3% | 50.0% of 4 |
| OB-GYN/ Pregnancy | 11 | 81.8% | — |
| Vision | 9 | 44.4% | 66.7% of 3 |
| Ears/Nose/Throat | 8 | 50.0% | 100.0% of 1 |
| Immuno Disorders | 7 | 28.6% | 0.0% of 2 |
| Infectious Disease | 7 | 28.6% | 50.0% of 2 |
| Respiratory System | 7 | 71.4% | 0.0% of 1 |
| Foot Disorder | 7 | 100.0% | — |
| Pediatrics | 5 | 0.0% | — |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 21 | 66.7% |
| 2022 | 13 | 53.8% |
| 2023 | 14 | 71.4% |
| 2024 | 8 | 62.5% |
| 2025 | 12 | 75.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 63 | 58.7% | 59.2% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 47 | 17.0% | 59.2% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 20 | 65.0% | 59.2% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 8 | 87.5% | 59.2% |
| Urgent or emergencyThe findings mention urgency. | 8 | 12.5% | 59.2% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 4 | 75.0% | 59.2% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for medical nutrition therapy with a registered dietician. Dietitians providing medical nutrition therapy can help overweight and obese individuals lose weight through behavioral strategies and a prescribed diet to reduce calorie intake. A meta-analysis of randomized controlled trials showed that medical nutritional therapy …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a reproductive endocrinologist consultation and/or a fertility specialist consultation. Although this patient does not currently have a diagnosis of infertility, the patient has had part of the pituitary resected. Evaluation by a reproductive endocrinologist is indicated, as the patient has major endocrine …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a referral for infertility services, including transvaginal ultrasound and office visits. The American Society for Reproductive Medicine (ASRM) notes that evaluation for infertility may be considered earlier than one year based on individual circumstances, including medical history and clinical findings. In this …”
- 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 SCP Consult Refer denials overturned?
In 348 California IMR decisions from 2001 to 2025, reviewers overturned the plan 206 times (59.2%). In the last five years: 66.2% of 68.
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.