Condition class · category · California
Dental denials at external review
When a California health plan denied care for dental and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
66.7%
- Overturned
- 22 of 33
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Dental Problems
- Median days to decision
- 52
- All years
- 54.4% of 160
Authorities named in this class
computed- American Academy of Neurology—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
- Dental & orthodontic procedures—20
- Acute inpatient medical—3
- Special procedures—3
- Orthopedic procedures—2
- Pharmacy—2
- Reconstructive & plastic procedures—2
- Outpatient rehabilitation—1
The specific treatments inside this class
below n=30, no rate is claimed- Orthodontia/ Braces—5
- Other—5
- Dental Implants—4
- Admission—3
- Dental Anesthesia—3
- General Anesthesia—3
- Bone Graft—2
- Jaw Surgery—2
By review type
computed- Medical Necessity68.8%32
- 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.