Condition class · subcategory · California
Lung denials at external review
When a California health plan denied care for lung and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
63.0%
- Overturned
- 29 of 46
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Lung
- Median days to decision
- 25
- All years
- 53.6% of 263
Authorities named in this class
computed- NCCN—27
- FDA—5
- American College of Rheumatology—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
- Cancer Care—21
- Diagnostic imaging & screening—19
- Pharmacy—4
- Acute inpatient medical—1
- Special procedures—1
The specific treatments inside this class
below n=30, no rate is claimed- Genetic/Genomic Test—16
- Cancer Rx—15
- Radiation Therapy—4
- Biologics—2
- CT Scan—2
- Proton Beam—2
- Admission—1
- Other—1
By review type
computed- Experimental/Investigational—25
- Medical Necessity—21
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.