Genetic 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—27
• American College of Cardiology—2
• American Heart Association—2
• NCCN—2
• American Academy of Neurology—1
• American Academy of Ophthalmology—1
• American College of Physicians—1
• Cochrane—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.

• Pharmacy68.6%51
• Durable medical equipment—27
• Diagnostic imaging & screening—19
• Outpatient rehabilitation—13
• Home Health Care—6
• Autism-related treatment—3
• Acute inpatient medical—2
• Diagnostic & physician evaluation—2

Browse all treatment classes · Pick your own pair

• Other—24
• Genetic/Genomic Test—15
• Biologics—10
• Neuromuscular RX—8
• Hormones—6
• Physical Therapy—6
• Skill Nsg Vsts—6
• Speech Therapy—6

• Medical Necessity64.3%115
• Experimental/Investigational—19

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.