Condition class · subcategory · California
Lupus denials at external review
When a California health plan denied care for lupus and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
62.9%
- Overturned
- 22 of 35
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Lupus
- Median days to decision
- 22
- All years
- 53.9% of 89
Authorities named in this class
computed- FDA—10
- American College of Rheumatology—8
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
- Pharmacy66.7%30
- Diagnostic imaging & screening—2
- Durable medical equipment—1
- Outpatient rehabilitation—1
- Vision Services/Ophthalmology—1
The specific treatments inside this class
below n=30, no rate is claimed- Biologics—11
- Anti-inflammatories—4
- Arthritis Rx—4
- Other—4
- Weight Control—4
- IVIG Therapy—2
- CT Scan—1
- Diabetic Medication—1
By review type
computed- Medical Necessity65.6%32
- Experimental/Investigational—3
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.