Condition class · subcategory · California
Brain denials at external review
When a California health plan denied care for brain and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
54.0%
- Overturned
- 27 of 50
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Brain
- Median days to decision
- 19
- All years
- 52.0% of 171
Authorities named in this class
computed- NCCN—29
- FDA—19
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
- Cancer Care55.6%36
- Diagnostic imaging & screening—4
- Durable medical equipment—3
- Acute inpatient medical—2
- Pharmacy—2
- Electro, thermal & radiofrequency—1
- Emergency & urgent care—1
- Outpatient rehabilitation—1
The specific treatments inside this class
below n=30, no rate is claimed- Cancer Rx—19
- Other—8
- Proton Beam—8
- Genetic/Genomic Test—4
- Chemotherapy—2
- Radiation Therapy—2
- Admission—1
- Biologics—1
By review type
computed- Medical Necessity—29
- Experimental/Investigational—20
- Urgent Care—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.