Cardiac & circulatory denials at external review

• rising

  It has risen over the published record: 29.3% in 2004 against 48.5% in 2025. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.

• most-cited standard

  Reviewers named American College of Cardiology more than any other standard here — 67 decisions, which came out at 59.7%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

• concentrated

  25% of these disputes involved cardiovascular procedures alone (n=147, 61.2% overturned), so the headline figure for cardiac & circulatory is largely that pairing.

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.

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.

• American College of Cardiology59.7%67
• American Heart Association61.1%54
• FDA63.0%46
• American College of Rheumatology—4
• American Diabetes Association—2
• American Academy of Neurology—1
• American Society of Addiction Medicine—1
• National Institutes of Health—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.

• Cardiovascular procedures61.2%147
• Diagnostic imaging & screening43.3%134
• Pharmacy56.7%104
• Durable medical equipment53.5%86
• Skilled nursing & inpatient rehab24.2%33
• Diagnostic & physician evaluation—18
• Acute inpatient medical—14
• Outpatient rehabilitation—12

Browse all treatment classes · Pick your own pair

• Other59.1%115
• Wearable Cardio Defib68.4%38
• Surgery75.8%33
• Cardiac Rx40.6%32
• Weight Control75.0%32
• CT Scan20.0%30
• Heart Monitor—24
• Vein Ablation—20

• Medical Necessity49.4%340
• Experimental/Investigational56.8%243
• Urgent Care—3

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.