Crohn's Disease denials at external review

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.

• FDA—23
• American Gastroenterological Association—14
• MCG / Milliman—2

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.

• Pharmacy86.2%123
• Diagnostic imaging & screening—7
• Home Health Care—2
• Skilled nursing & inpatient rehab—2

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• Biologics88.5%61
• Digestion/GI Rx84.9%53
• Lab Work—3
• Other—3
• Genetic/Genomic Test—2
• IVIG Therapy—2
• Inject/ Infus—2
• Inpt Admission—2

• Medical Necessity87.9%116
• Experimental/Investigational—18

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.