Stent for Cardiac/Circ Problem: 69.6% of denials overturned
In 23 California IMR decisions from 2007 to 2025, reviewers overturned 16 (69.6%). In the last five years: 60.0% of 10. 12 were medical-necessity disputes, 11 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 100.0% |
| 2022 | 1 | 0.0% |
| 2023 | 4 | 50.0% |
| 2024 | 1 | 100.0% |
| 2025 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 10 | 60.0% | 69.6% |
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 an enrollee has requested authorization and coverage for stent placement. Current medical literature supports venous stenting as an effective treatment for idiopathic intracranial hypertension (IIH). In this case, the patient has failed conservative management, including the standard therapies of medications, aspirin, ibuprofen, Imitrex, Ubrelvy, Tylenol, naproxen, acetazolamide, topiramate, tramadol, Botox, Nurtec, exercise, nutrition, weight loss, …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for venous angioplasty with or without stent placement. The requested intervention is indicated for this patient given her typical symptomatology and objective radiological findings. Although the patient presents with a rare condition, her presentation and prognosis are well documented for several years. The …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for extracranial carotid artery stenting (CAS). Per the available records, this patient is a high surgical risk to undergo CEA because he has bilateral carotid stenosis with left- and right-sided occlusion. This supports that the patient is at high-risk to undergo CEA. Moreover, there are adequate data supporting …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a coronary angiogram with stent placement. Per the medical records, the patient has coronary artery disease without evidence of flow limitation by symptoms or by stress echocardiogram. While computed tomography fractional flow reserve (CT-FFR) results were noted as abnormal, this method 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 Stent denials for Cardiac/Circ Problem overturned?
In 23 California IMR decisions from 2007 to 2025, reviewers overturned 16 (69.6%). In the last five years: 60.0% of 10. 12 were medical-necessity disputes, 11 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.