Condition class · subcategory · California
Breathing Problem denials at external review
When a California health plan denied care for breathing problem and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
63.3%
- Overturned
- 19 of 30
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Breathing Problem
- Median days to decision
- 24
- All years
- 56.8% of 44
Authorities named in this class
computed- American College of Rheumatology—2
- FDA—2
- American College of Cardiology—1
- MCG / Milliman—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
- Durable medical equipment—12
- Diagnostic imaging & screening—7
- Acute inpatient medical—3
- Pharmacy—3
- Skilled nursing & inpatient rehab—3
- Emergency & urgent care—1
- General surgery—1
The specific treatments inside this class
below n=30, no rate is claimed- Other—11
- Admission—2
- Asthma Rx—2
- CT Scan—2
- Inpt Admission—2
- Oxygen—2
- Pneumatic Vest—2
- Biologics—1
By review type
computed- Medical Necessity—22
- Experimental/Investigational—7
- 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.