Surgery for Cardiac/Circ Problem: 77.5% of denials overturned
In 40 California IMR decisions from 2019 to 2025, reviewers overturned 31 (77.5%). In the last five years: 75.8% of 33. 9 were medical-necessity disputes, 31 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 11 | 81.8% |
| 2022 | 5 | 60.0% |
| 2023 | 4 | 75.0% |
| 2024 | 6 | 83.3% |
| 2025 | 7 | 71.4% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 20 | 75.0% | 77.5% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 6 | 100.0% | 77.5% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 77.5% |
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 a patient has requested authorization and coverage for endovascular revascularization with atherectomy, including angioplasty, of both lower extremities.The current medical literature and the records provided support the requested endovascular revascularization with atherectomy, including angioplasty, of both lower extremities as medically necessary for the treatment of this patient. Clinical documentation reflects symptoms and objective findings consistent …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for surgery to implant a carotid sinus baroreflex activation device.Based on the available clinical documents, this patient has a history of New York Heart Association (NYHA) class III heart failure symptoms despite medical management with a left ventricular ejection fraction (LVEF) of less …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a stab phlebectomy procedure. Varicose veins are usually caused by superficial venous incompetence, which may involve the saphenous veins, their tributaries, or both. Studies have shown that treatment of patients presenting with great saphenous vein (GSV) reflux and a large varicose GSV …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an endovascular revascularization of an initial, unilateral iliac artery, which includes transluminal stent placement and angioplasty procedure. The provided documentation does not support the medical necessity of the requested procedure. There is a lack of clarity as to the etiology of the …”
- 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 Surgery denials for Cardiac/Circ Problem overturned?
In 40 California IMR decisions from 2019 to 2025, reviewers overturned 31 (77.5%). In the last five years: 75.8% of 33. 9 were medical-necessity disputes, 31 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.