Skin Treatment for Skin Disorders: 67.4% of denials overturned
In 448 California IMR decisions from 2002 to 2025, reviewers overturned 302 (67.4%). In the last five years: 81.2% of 197. 430 were medical-necessity disputes, 18 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 45 | 82.2% |
| 2022 | 35 | 74.3% |
| 2023 | 38 | 76.3% |
| 2024 | 59 | 84.7% |
| 2025 | 20 | 90.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 186 | 76.3% | 67.4% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 140 | 73.6% | 67.4% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 86 | 40.7% | 67.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 55 | 3.6% | 67.4% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 40 | 72.5% | 67.4% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 40 | 62.5% | 67.4% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 35 | 65.7% | 67.4% |
| Urgent or emergencyThe findings mention urgency. | 4 | 75.0% | 67.4% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Duobrii topical lotion. Initial treatment of psoriasis is with topical treatments. Duobrii topical lotion is a combination of halobetasol and tazarotene, and is U.S. Food and Drug Administration (FDA)-approved for psoriasis. In this case, the patient has a diagnosis of psoriasis. The …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Cibinqo. Moderate-to-severe atopic dermatitis can be difficult to treat. This patient has tried and failed topical treatments, including topical steroids. There are several U.S. Food and Drug Administration (FDA)-approved advanced treatments for atopic dermatitis, including Cibinqo. Cibinqo is FDA-approved for the treatment …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for triamcinolone acetonide aerosol solution. The submitted documentation supports the medical necessity of the requested medication. Pyoderma gangrenosum is a painful ulcerative immune-mediated dermatosis associated with inflammatory bowel disease. It often occurs in the skin around an ostomy, as is the case with …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested authorization and coverage for tacrolimus 0.1%. Topical corticosteroids remain the standard first-line treatment for atopic dermatitis, with strong evidence supporting their effectiveness. Alternative non-steroidal topical therapies are also available for select patients. In this clinical setting, there is insufficient evidence demonstrating that tacrolimus 0.1% …”
- 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 Skin Treatment denials for Skin Disorders overturned?
In 448 California IMR decisions from 2002 to 2025, reviewers overturned 302 (67.4%). In the last five years: 81.2% of 197. 430 were medical-necessity disputes, 18 experimental/investigational.
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.