Condition class · subcategory · California
Abdominal/Stomach Pain denials at external review
When a California health plan denied care for abdominal/stomach pain and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
63.6%
- Overturned
- 21 of 33
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Abdominal/Stomach Pain
- Median days to decision
- 29
- All years
- 62.9% of 62
Authorities named in this class
computed- American College of Rheumatology—4
- American College of Physicians—1
- American Gastroenterological Association—1
A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.
By treatment
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Diagnostic imaging & screening—21
- Pharmacy—4
- General surgery—2
- Special procedures—2
- Alternative treatment—1
- Diagnostic & physician evaluation—1
- Emergency & urgent care—1
- Outpatient rehabilitation—1
The specific treatments inside this class
below n=30, no rate is claimed- CT Scan—8
- MRI—4
- Other—4
- Colonoscopy/Sigmoid—2
- Digestion/GI Rx—2
- Endoscopy—2
- Pain Medication—2
- Ultrasound—2
By review type
computed- Medical Necessity60.0%30
- Urgent Care—2
- Experimental/Investigational—1
Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.
Every figure on this page is conditional on a denial having reached external review. Fewer than 1% of denials are appealed internally at all, so this describes denials that were fought to the end — not denials in general — and it describes California only. Who this does not cover.
Free help, first: the California DMHC Help Center files your Independent Medical Review at no cost — 1-888-466-2219, dmhc.ca.gov.