Condition class · subcategory · California
Coronary Artery Disease denials at external review
When a California health plan denied care for coronary artery disease and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
26.7%
- Overturned
- 8 of 30
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Coronary Artery Disease
- Median days to decision
- 33
- All years
- 41.3% of 46
What stands out here
computed from this classamong the lowest
At 26.7%, this is the 6th-lowest overturn rate of the 72 conditiones carrying one — one of the few where reviewers more often agreed with the plan than not.
Authorities named in this class
computed- American College of Cardiology—9
- FDA—7
- American Heart Association—6
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
- Pharmacy—12
- Diagnostic imaging & screening—10
- Cardiovascular procedures—5
- Durable medical equipment—2
- Skilled nursing & inpatient rehab—1
The specific treatments inside this class
below n=30, no rate is claimed- Cardiac Rx—6
- Other—5
- CT Scan—4
- Biologics—3
- Glucagon-Like Peptide-1 (GLP)—3
- Lab Work—2
- Wearable Cardio Defib—2
- Cardiac Mapping—1
By review type
computed- Medical Necessity—22
- Experimental/Investigational—8
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.