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Everything here is free to read, and nothing here is a claim about your case. Built from California’s published records and modified by us — not official government data. How these numbers were made.

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Condition class · subcategory · California

Alcohol Use Disorder denials at external review

When a California health plan denied care for alcohol use disorder and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.

80.1%

Overturned
149 of 186
Era
2021-2025
Jurisdiction
California DMHC IMR
Published class
Alcohol Use Disorder
Median days to decision
19
All years
82.4% of 216
149 overturned37 upheld

What stands out here

computed from this class

  • most-cited standard

    Reviewers named American Society of Addiction Medicine more than any other standard here — 173 decisions, which came out at 79.8%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

The trend, with its era

computed
0%25%50%75%100%97.4%20202025Share of decisions overturning the health plan · years below n=30 omitted

Hover the chart for a year’s counts. Series stops at 2025 — report year 2026 uses a different category vocabulary.

What reviewers relied on

3 validated codes

California requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.

What the reviewer relied onIn overturnsIn upholds
the FDA label or approval status0%n=1490%n=37
a standardised level-of-care instrument97%n=14997%n=37
a California statutory definition2%n=1490%n=37

Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.

Authorities named in this class

computed
  • American Society of Addiction Medicine79.8%173
  • LOCUS family—7
  • American Academy of Child and Adolescent Psychiatry—1
  • American Psychiatric 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
  • Mental Health80.0%185
  • Pharmacy—1

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The specific treatments inside this class

below n=30, no rate is claimed
  • RTC80.2%177
  • Partial Hospital—5
  • Intensive Outpt Prog—2
  • Acute Psych—1
  • Other—1

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.