Condition class · subcategory · California
Headache denials at external review
When a California health plan denied care for headache and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
60.0%
- Overturned
- 24 of 40
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Headache
- Median days to decision
- 30
- All years
- 42.3% of 260
Authorities named in this class
computed- American College of Rheumatology—3
- American Diabetes Association—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
- Pain Management—18
- Diagnostic imaging & screening—7
- Pharmacy—4
- Diagnostic & physician evaluation—2
- Electro, thermal & radiofrequency—2
- Acute inpatient medical—1
- Alternative treatment—1
- Durable medical equipment—1
The specific treatments inside this class
below n=30, no rate is claimed- Nerve Block—16
- MRI—6
- Other—5
- Migraine Rx—2
- Acupuncture—1
- Admission—1
- Artificial Disc Repl—1
- Botox Injection—1
By review type
computed- Experimental/Investigational—20
- Medical Necessity—20
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.