SCP Consult Refer for Endocrine/Metabolic: 43.8% of denials overturned
In 16 California IMR decisions from 2002 to 2025, reviewers overturned 7 (43.8%). In the last five years: 50.0% of 4. 16 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 0.0% |
| 2025 | 2 | 100.0% |
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). | 4 | 0.0% | 43.8% |
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 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 …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for depo-testosterone, non-statin cholesterol medication, and a consultation with a urologist. Based on the available documentation, this patient should have ongoing follow-up for his symptoms with a urologist. However, there is a lack of documentation to support the need for testosterone treatment as there is no record of …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for referral to a registered dietician. Findings: The physician reviewer found that treatment of adult obesity includes education and training regarding a comprehensive lifestyle change with dietary therapy, exercise, behavior modification, and if needed, drug therapy. Identifying an individual’s risk for adverse medical outcomes due to obesity is …”
- 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 Endocrine/Metabolic overturned?
In 16 California IMR decisions from 2002 to 2025, reviewers overturned 7 (43.8%). In the last five years: 50.0% of 4. 16 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.