Condition class · subcategory · California
Joint Problem/Pain denials at external review
When a California health plan denied care for joint problem/pain and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
50.0%
- Overturned
- 23 of 46
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Joint Problem/Pain
- Median days to decision
- 23
- All years
- 50.8% of 65
Authorities named in this class
computed- American College of Rheumatology—6
- FDA—1
- IDSA—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
- Orthopedic procedures—11
- Pain Management—9
- Diagnostic imaging & screening—8
- Durable medical equipment—7
- Pharmacy—5
- Alternative treatment—2
- Electro, thermal & radiofrequency—2
- Outpatient rehabilitation—1
The specific treatments inside this class
below n=30, no rate is claimed- Other—9
- MRI—7
- Fusion—4
- Nerve Block—3
- Orthotics—3
- Pain Medication—3
- Arthroscopy—2
- Biologics—2
By review type
computed- Medical Necessity47.1%34
- Experimental/Investigational—12
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.