Condition class · category · California
Blood disorders denials at external review
When a California health plan denied care for blood disorders and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
50.9%
- Overturned
- 29 of 57
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Blood Related Disord
- Median days to decision
- 41
- All years
- 47.6% of 206
Authorities named in this class
computed- FDA—10
- NCCN—4
- American College of Cardiology—2
- American Gastroenterological Association—2
- American Heart Association—2
- American College of Obstetricians and Gynecologists—1
- American College of Rheumatology—1
- American Urological 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
- Pharmacy53.1%32
- Diagnostic imaging & screening—17
- Acute inpatient medical—2
- Durable medical equipment—1
- Electro, thermal & radiofrequency—1
- Home Health Care—1
- Pain Management—1
- Skilled nursing & inpatient rehab—1
The specific treatments inside this class
below n=30, no rate is claimed- Other—11
- Vitamins—10
- Genetic/Genomic Test—7
- Biologics—5
- CT Scan—3
- Lab Work—3
- IVIG Therapy—2
- Weight Control—2
By review type
computed- Medical Necessity50.0%40
- Experimental/Investigational—17
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.