Condition class · subcategory · California
Brain Injury/Concussion denials at external review
When a California health plan denied care for brain injury/concussion and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
50.0%
- Overturned
- 21 of 42
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Brain Injury/Concussion
- Median days to decision
- 44
- All years
- 45.8% of 59
Authorities named in this class
computed- American Academy of Neurology—1
- American College of Rheumatology—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
- Outpatient rehabilitation—9
- Acute inpatient medical—8
- Skilled nursing & inpatient rehab—8
- Diagnostic imaging & screening—4
- Transportation—4
- Durable medical equipment—3
- Diagnostic & physician evaluation—2
- Alternative treatment—1
The specific treatments inside this class
below n=30, no rate is claimed- Admission—6
- Inpt Admission—5
- Trau Brain Inj Prog—5
- Non Emerg Med (NEMT)—4
- Other—3
- Physical Therapy—3
- Adult ICU—2
- Inpt Discharge—2
By review type
computed- Medical Necessity54.1%37
- Experimental/Investigational—5
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.