Condition class · subcategory · California
Epilepsy denials at external review
When a California health plan denied care for epilepsy and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
90.3%
- Overturned
- 28 of 31
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Epilepsy
- Median days to decision
- 25
- All years
- 77.3% of 119
What stands out here
computed from this classamong the highest
At 90.3%, this is the highest overturn rate of the 72 conditiones with enough decisions to publish one. Reviewers sustained the plan in the remaining 9.7% of disputes.
Authorities named in this class
computed- FDA—7
- American Academy of Neurology—2
- American Academy of Child and Adolescent Psychiatry—1
- LOCUS family—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
- Pharmacy—17
- Durable medical equipment—5
- Neurosurgery—4
- Diagnostic imaging & screening—2
- Autism-related treatment—1
- Diagnostic & physician evaluation—1
- Mental Health—1
The specific treatments inside this class
below n=30, no rate is claimed- Epileptic Medication—9
- Other—9
- IVIG Therapy—2
- ADD/ADHD Rx—1
- Anxiety Rx—1
- Appld Behav Analysis—1
- Biologics—1
- Craniotomy—1
By review type
computed- Medical Necessity—23
- 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.