SCP Consult Refer for Cardiac/Circ Problem: 65.8% of denials overturned
In 38 California IMR decisions from 2002 to 2025, reviewers overturned 25 (65.8%). In the last five years: 76.9% of 13. 38 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 9 | 88.9% |
| 2022 | 1 | 0.0% |
| 2023 | 1 | 0.0% |
| 2024 | 1 | 100.0% |
| 2025 | 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. | 6 | 100.0% | 65.8% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 65.8% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for referral to an autonomic specialist. Per the medical records, the patient has undergone neurological and cardiology evaluations for episodes of loss of consciousness. The neurology evaluation notes a working diagnosis of functional neurological disorder, while the cardiologist notes that the patient has …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cortisone injection in the left knee. The patient presents with a history of left lateral knee pain with a diagnosis of iliotibial band syndrome. As noted in the records, the patient is not a runner and there is no history of trauma. …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for urine tests (albumin to creatinine ratio (ACR) and glomerular filtration rate (GFR)).McTaggart and colleagues state that albuminuria is an important sign of chronic kidney disease and is detected routinely by measurement of urinary ACR. Additionally, Ranch states that proteinuria in certain conditions can signify renal disease and …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a specialist for tertiary level of care. Patients with inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) are most often referred to and cared for by electrophysiologists (EPs) due to the arrhythmic nature of the accompanying symptoms of …”
- 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 for Cardiac/Circ Problem overturned?
In 38 California IMR decisions from 2002 to 2025, reviewers overturned 25 (65.8%). In the last five years: 76.9% of 13. 38 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.