# The Apellica External Review Index — Methodology

**Dataset version:** 1.0
**Released:** 2026-05-19
**Resource package updated:** 2026-09-04
**License:** Creative Commons Attribution 4.0 International (CC-BY-4.0) — https://creativecommons.org/licenses/by/4.0/
**Canonical URL:** https://apellica.com/external-review-index
**Corrections:** editorial@apellica.com

## What this dataset is

A public-record survey of how often each U.S. jurisdiction's independent
external-review program (or the HHS-administered federal process) overturns a
health-insurance denial. It covers 56 jurisdictions: all 50 states, the
District of Columbia, and 5 U.S. territories. 14 of 56
jurisdictions publish a discoverable reversal figure; 42 do not.
47 run a state program; 9 rely on the
HHS-administered federal process.

Every numeric cell is anchored to a single primary public-record source URL,
listed in the table below and in the CSV.

## What this dataset is NOT

- **Not a like-for-like ranking.** Denominators are not comparable across
  jurisdictions: some count cases *received*, some *completed*, some
  *completed-and-eligible*. A few (e.g. California, Maryland, Connecticut)
  publish a broader complaint-process reversal rate that includes insurer
  concessions before a formal IRO decision.
- **Not extrapolated.** Where a jurisdiction does not publish a figure, the
  cell is left empty. No missing value is imputed and no precision is added
  beyond what the source states.
- **Not a national average.** We deliberately do not roll a single number up
  from non-comparable denominators.
- **Not Medicare or workers' comp.** Medicare Advantage IRE data and
  workers'-compensation IMR data are excluded; they are separate regimes.

## Caveat categories

Each row carries a verbatim note. The recurring flags are:

- **HHS-administered** — federal process; CMS does not publish jurisdiction-level totals.
- **Cumulative multi-year** — the rate spans multiple years, not a single year.
- **Broader than IRO-only** — a complaint/grievance reversal rate wider than strict external review.
- **Stale / secondary citation** — historic (e.g. KFF) or press-attributed figure, flagged.
- **Data gap** — the jurisdiction does not publish a discoverable current statistic.

## How to cite

> Apellica (2026). The Apellica External Review Index: U.S. State External-Review Reversal Rates 2026. v1.0. Released 2026-05-19; resource package updated 2026-09-04. CC-BY-4.0. https://apellica.com/external-review-index

## Corrections and updates

This dataset is versioned at a single canonical URL. To submit a correction,
email editorial@apellica.com with (1) the jurisdiction, (2) the value or source
you believe is correct, and (3) a public-record URL. Verified corrections are
folded into the next dated resource update and noted in the changelog. Apellica
is an independent appeal-preparation service — not a regulator, law firm, or
insurer — republishing public regulatory data as a free research resource.

## Full source table

| Jurisdiction | Abbrev | Year | Reversal rate | System | Source | Note |
| --- | --- | --- | --- | --- | --- | --- |
| Alabama | AL | 2024 | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | Data gap: HHS-administered process; CMS does not publish state-level case totals. Alabama has no state-run external review system. |
| Alaska | AK | — | — | state-run | https://www.commerce.alaska.gov/web/ins/AboutUs/AnnualReports.aspx | Data gap: Division publishes annual reports but does not publicly itemize IRO external-review case totals or overturn rates. |
| Arizona | AZ | 2014 | 21.0% | state-run | https://www.kff.org/affordable-care-act/state-indicator/external-appeals-review-processes/ | Historic KFF-cited figure (21%). DIFI does not publish a current external-review annual report; flagged as stale. |
| Arkansas | AR | — | — | state-run | https://insurance.arkansas.gov/pages/consumer-services/health-insurance/ | Data gap: Arkansas Insurance Department does not publish a public external-review annual statistics report. |
| California | CA | 2024 | 72.7% | state-run | https://www.dmhc.ca.gov/Resources/DMHCReports/AnnualReports.aspx | Headline: ~73% of IMR cases end with enrollee receiving requested service (full+partial overturn by IMRO + plan reversals during review). Of cases reaching final IMRO determination, overturn rate of treatment-denial decisions was 12.7% in 2024 (up from 10.2% in 2023). Full open-data trend file: https://data.chhs.ca.gov/dataset/independent-medical-review-imr-determinations-trend |
| Colorado | CO | 2024 | 44.0% | state-run | https://doi.colorado.gov/colorado-insurance-industry-statistical-report | ~44% overturn rate cited by Division (per NBC News 2025 coverage attributing to DORA). Statistical report exists but item-level external-review tables not extracted; flag as secondary citation. |
| Connecticut | CT | 2024 | 80.0% | state-run | https://portal.ct.gov/cid/searchable-archive/consumer-affairs/how-to-guides/how-and-when-to-file-an-external-review | Healthcare Advocate office reports denials resolved/overturned in patient's favor ~80% of cases. Counts include both formal IRO reversals and pre-decision insurer concessions after advocate involvement. CT total denial rate among largest insurers was 14% in 2024. |
| Delaware | DE | — | — | state-run | https://insurance.delaware.gov/services/iharp/ | Data gap: Delaware's Independent Health Care Appeals Program (IHCAP) does not publicly post external-review tabular statistics. |
| District of Columbia | DC | — | — | state-run | https://disb.dc.gov/page/insurance-bureau | Data gap: DISB does not publish a dedicated external-review annual statistics document. |
| Florida | FL | 2024 | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | Florida participates in HHS-administered federal external review (no compliant state-run process for federally regulated plans). FL OIR does not publish corresponding overturn statistics. Data gap on state-level totals. |
| Georgia | GA | 2024 | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | Georgia uses HHS-administered federal external review process per CMS classification (KFF 2024 listing). OCI took over Patient Rights to Independent Review Act duties from DCH on 2022-07-01 but does not publish overturn statistics. |
| Hawaii | HI | 2023 | — | state-run | https://cca.hawaii.gov/ins/files/2024/02/2023-Annual-External-Review-Report.Final-Draft.pdf | Data gap on count fields: Hawaii does publish an Annual External Review Report (2023 most recent located). Underlying PDF binary not parseable in our pipeline; cite the report URL directly. |
| Idaho | ID | — | — | state-run | https://doi.idaho.gov/consumers/external-review/ | Data gap: Idaho DOI does not publish public external-review statistics. |
| Illinois | IL | 2024 | — | state-run | https://idoi.illinois.gov/content/dam/soi/en/web/insurance/reports/reports/2024-annual-report-to-the-governor-idoi.pdf | Data gap on count fields: IDOI Annual Report to the Governor 2024 references external-review program but tabular case counts not extracted from binary PDF in our pipeline. Hotline: 877-850-4740. |
| Indiana | IN | — | — | state-run | https://www.in.gov/idoi/companyentity-financial-compliance/other-entities-initial-registration-requirements/independent-review-organization-initial-registration/ | Data gap: IROs must file annual reports with IDOI but the Department does not publish a consolidated public external-review statistics document. |
| Iowa | IA | — | — | state-run | https://iid.iowa.gov/consumers/insurance/health-insurance/external-review | Data gap: Iowa Insurance Division publishes annual reports but does not specifically itemize external-review overturn statistics in a discoverable form. |
| Kansas | KS | 2024 | 54.0% | state-run | https://insurance.ks.gov/documents/department/publications/Annual-Report-2024.pdf | ~54% overturn rate cited by NBC News (2025) attributing to Kansas Department of Insurance covering data since 2018. Cumulative period rate; not single-year. Department publishes Independent Medical Review program at: https://insurance.ks.gov/documents/department/publications/independent-medical-review.pdf |
| Kentucky | KY | — | — | state-run | https://insurance.ky.gov/ppc/Pages/External-Review.aspx | Data gap: Kentucky DOI does not publish public external-review statistics. |
| Louisiana | LA | — | — | state-run | https://www.ldi.la.gov/ | Data gap: LDOI does not publish public external-review overturn statistics. |
| Maine | ME | 2023 | — | state-run | https://digitalmaine.com/bi_docs/139/ | Maine's Consumer Health Care Division publishes annual external review report incorporated into Superintendent's 2023 Annual Report. Specific case counts not extracted from binary PDF in our pipeline; cite source URL directly. |
| Maryland | MD | 2024 | 66.8% | state-run | https://insurance.maryland.gov/Consumer/Appeals%20and%20Grievances%20Reports/Health-Care-Appeals-and-Grievance-Law-2024-Report-Insurance-Article-15-10A-06-b-3.pdf | MIA reversed or modified the carrier's grievance decision 66.8% of the time in 2024, per MIA's 2024 Health Care Appeals and Grievance Law Report. Down 2.9 pts from prior year. Note: this is MIA's complaint-handling reversal rate, broader than IRO-only external review. Source PDF identified. |
| Massachusetts | MA | 2023 | 40.0% | state-run | https://masshpc.gov/publications/office-patient-protection-report/2023-office-patient-protection-annual-report | ~40% of OPP external reviews resolved in patient's favor per OPP 2023 Annual Report referenced by MA HPC. 2024 report not yet located; flag as most-recent-published is 2023. |
| Michigan | MI | 2024 | — | state-run | https://www.michigan.gov/difs/-/media/Project/Websites/difs/Annual_Report/DIFS_Annual_Report.pdf | Data gap on count fields: DIFS publishes PRIRA (Patient's Right to Independent Review Act) decisions individually on its site but does not publish consolidated overturn statistics in a discoverable form. 2024 DIFS Annual Report identified. |
| Minnesota | MN | 2024 | 43.0% | state-run | https://mn.gov/commerce/insurance/health/consumer-protections/external-review.jsp | 43% of external reviews resulted in coverage denials being overturned in 2024, per Department of Commerce (cited via KSTP News). Filing fee dropped 2024-08-01 to increase access. |
| Mississippi | MS | 2024 | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | Mississippi historically classified as relying on HHS-administered federal process. Note KFF 2024 state list only flags 5 states (AL/FL/GA/TX/WI); MS may have shifted classification. Flag for re-verification. |
| Missouri | MO | — | — | state-run | https://insurance.mo.gov/reports | Data gap: Missouri DCI does not publish public external-review overturn statistics. |
| Montana | MT | — | — | state-run | https://csimt.gov/insurance/health-insurance/ | Data gap: CSI Montana does not publish public external-review statistics. |
| Nebraska | NE | — | — | state-run | https://doi.nebraska.gov/consumer/health-insurance | Data gap: Nebraska DOI does not publish public external-review statistics. Note: NE was previously HHS-administered; KFF 2024 list shows state-run, flag for verification. |
| Nevada | NV | — | — | state-run | https://doi.nv.gov/Insurers/Life-Health/Required-Industry-Reports/ | Data gap: Nevada Division of Insurance does not publish a discoverable external-review statistics report. |
| New Hampshire | NH | — | — | state-run | https://www.insurance.nh.gov/consumers/health-insurance/independent-external-review | Data gap: NHID 2025 Annual Report identified but specific external-review counts not extracted. |
| New Jersey | NJ | — | — | state-run | https://www.nj.gov/dobi/division_insurance/managedcare/ihcap.htm | Data gap on count fields: DOBI's Independent Health Care Appeals Program (IHCAP) publishes periodic reports (48th IHCAP report identified) but case-level statistics not extracted from binary PDF in our pipeline. KFF 1998-era data cited Connecticut + NJ in 50-72% historic range. |
| New Mexico | NM | — | — | state-run | https://www.osi.state.nm.us/consumer/ | Data gap: NM OSI does not publish public external-review overturn statistics. |
| New York | NY | 2024 | — | state-run | https://www.dfs.ny.gov/system/files/documents/2025/06/NYSDFS_Annual-Report-2024.pdf | NY DFS publishes the most extensive external-appeal database in the US (searchable: https://www.dfs.ny.gov/public-appeal/search). Aggregate 2024 counts referenced in DFS 2024 Annual Report; specific tables not extracted from binary PDF in our pipeline. Independent dashboard at https://appeal-explorer.persius.org |
| North Carolina | NC | 2024 | 54.3% | state-run | https://www.ncdoi.gov/consumers/health-insurance/health-claim-denied/request-external-review | Smart NC received 282 external review requests through November 2024 and overturned 153 (~53%). Per Smart NC and NBC News reporting (2025). Annual report: https://www.ncleg.gov/Files/Library/agency/doi13339.pdf |
| North Dakota | ND | — | — | state-run | https://www.insurance.nd.gov/consumers/health | Data gap: ND Insurance Department does not publish public external-review statistics. |
| Ohio | OH | 2019 | — | state-run | https://dam.assets.ohio.gov/image/upload/insurance.ohio.gov/Legal/Reports/Documents/Annual_Health_Claims_External_Review_Report_2019.pdf | Data gap on count fields: Most recent publicly posted Annual Health Claims External Review Report is 2019. Ohio law requires annual publication but current-year reports not published online; flag as significant transparency gap. |
| Oklahoma | OK | — | — | state-run | https://www.oid.ok.gov/consumers/external-review-process/ | Data gap: OID does not publish public external-review statistics. |
| Oregon | OR | 2025 | 38.9% | state-run | https://dfr.oregon.gov/insure/health/understand/coverage/pages/iro-decision-report.aspx | Oregon DFR IRO Case Detail Report (current through 2025-06-30): 352 cases received, 278 completed full review, 108 overturned or partially overturned (39%), 170 upheld. Excel-format quarterly updates. |
| Pennsylvania | PA | 2025 | 48.4% | state-run | https://www.pa.gov/agencies/insurance/newsroom/shapiro-admin-ind-ext-review-helps-hundreds-receive-benefits-originally-denied | PA Independent External Review Program (launched 2024-01) referred 1353 eligible cases to IROs since inception through 2025; 655 overturned (~48%). First-year (2024) rate was 50.1%. Program is one of newest state-run replacements for HHS-administered process. |
| Rhode Island | RI | — | — | state-run | https://ohic.ri.gov/data-reports/ohic-additional-data-and-reports | Data gap: OHIC does not publish a discoverable external-review statistics document. |
| South Carolina | SC | 2024 | 43.0% | state-run | https://doi.sc.gov/ | ~43% of cases reversed in 2024 per NBC News attribution to SCDOI. SC DOI does not publish dedicated annual external-review report online; flag as secondary citation. |
| South Dakota | SD | — | — | state-run | https://dlr.sd.gov/insurance/external_review/company_review_process.aspx | Data gap: SD Division of Insurance publishes IRO process documentation but no overturn statistics. |
| Tennessee | TN | — | — | state-run | https://www.tn.gov/commerce/insurance-division.html | Data gap: TDCI returned $17.54M to consumers via mediation in 2024 but does not break out external-review overturn statistics. |
| Texas | TX | — | — | state-run | https://www.tdi.texas.gov/hmo/mcqa/indexiro.html | Data gap on count fields: TDI publishes IRO decisions individually but does not publish consolidated overturn statistics. Note: KFF 2024 lists TX as HHS-administered; TDI operates state-level IRO process for workers' compensation and certifies IROs. Methodology divergence: TX IRO data structure differs materially from CA DMHC IMR; not directly comparable. |
| Utah | UT | — | — | state-run | https://insurance.utah.gov/consumers/health/ | Data gap: Utah Insurance Department does not publish public external-review statistics. |
| Vermont | VT | — | — | state-run | https://dfr.vermont.gov/industry/insurance/health-insurance/reports | Data gap: Vermont DFR publishes Health Insurers Annual Reports with claims/appeals data but does not specifically itemize external-review overturn rates in a public summary. |
| Virginia | VA | — | — | state-run | https://www.scc.virginia.gov/consumers/insurance/health-insurance-consumer/external-review/ | Data gap: VA Bureau of Insurance does not publish a discoverable external-review statistics report. |
| Washington | WA | 2024 | 25.0% | state-run | https://www.insurance.wa.gov/sites/default/files/2025-07/OIC-annual-report-2024-final.pdf | ~25% overturn rate in 2024 per NBC News attribution to WA OIC. 2024 WA OIC Annual Report identified. |
| West Virginia | WV | 2024 | 17.0% | state-run | https://www.wvinsurance.gov/Resources_Reports | ~17% overturn rate over the last 5 years (through 2024) per NBC News attribution to WV OIC. Cumulative period rate; not single-year. Significantly below national average. |
| Wisconsin | WI | 2024 | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | Wisconsin operates partial state external-review framework but classified by KFF (2024) as relying on HHS-administered process for the full external-review pathway. WI OCI 2024 Wisconsin Insurance Report identified at https://oci.wi.gov/Documents/AboutOCI/2024_WIR.pdf |
| Wyoming | WY | — | — | state-run | http://doi.wyo.gov/ | Data gap: WY DOI does not publish public external-review statistics. |
| American Samoa | AS | — | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | U.S. territory using HHS-administered federal process. CMS does not publish jurisdiction-level case totals. |
| Guam | GU | — | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | U.S. territory using HHS-administered federal process. CMS does not publish jurisdiction-level case totals. |
| Northern Mariana Islands | MP | — | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | U.S. territory using HHS-administered federal process. CMS does not publish jurisdiction-level case totals. |
| Puerto Rico | PR | — | — | state-run | https://ocs.pr.gov/ | KFF 2024 classifies Puerto Rico as operating an NAIC-parallel state-run external-review process; OCS does not publish public overturn statistics. |
| U.S. Virgin Islands | VI | — | — | HHS-administered | https://maximusferp.my.site.com/FERP/s/ | U.S. territory using HHS-administered federal process. CMS does not publish jurisdiction-level case totals. |