Condition class · subcategory · California
Irritable Bowel Syndrome denials at external review
When a California health plan denied care for irritable bowel syndrome and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
69.2%
- Overturned
- 27 of 39
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Irritable Bowel Syndrome
- Median days to decision
- 30
- All years
- 67.3% of 52
Authorities named in this class
computed- FDA—13
- American Gastroenterological Association—3
- MCG / Milliman—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—29
- Diagnostic imaging & screening—4
- Diagnostic & physician evaluation—2
- Alternative treatment—1
- Durable medical equipment—1
- Electro, thermal & radiofrequency—1
- Special procedures—1
The specific treatments inside this class
below n=30, no rate is claimed- Digestion/GI Rx—21
- Antibiotics—7
- Lab Work—2
- Other—2
- SCP Consult Refer—2
- Acupuncture—1
- Biologics—1
- Colonoscopy/Sigmoid—1
By review type
computed- Medical Necessity73.5%34
- Experimental/Investigational—5
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.