Condition class · subcategory · California
Lymphedema denials at external review
When a California health plan denied care for lymphedema and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
71.8%
- Overturned
- 28 of 39
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Lymphedema
- Median days to decision
- 39
- All years
- 64.0% of 89
Authorities named in this class
computed- FDA—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
- Durable medical equipment—18
- Cardiovascular procedures—12
- General surgery—4
- Diagnostic imaging & screening—3
- Diagnostic & physician evaluation—1
- Reconstructive & plastic procedures—1
The specific treatments inside this class
below n=30, no rate is claimed- Other—17
- Compression Garments—14
- Surgery—5
- Bariatric Surgery—1
- MRI—1
- OON Referral—1
By review type
computed- Experimental/Investigational83.3%30
- Medical Necessity—9
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.