Condition class · subcategory · California
Migraine denials at external review
When a California health plan denied care for migraine and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
82.5%
- Overturned
- 174 of 211
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Migraine
- Median days to decision
- 28
- All years
- 63.5% of 636
What stands out here
computed from this classrising
It has risen over the published record: 63.3% in 2010 against 88.9% in 2025. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.
most-cited standard
Reviewers named FDA more than any other standard here — 103 decisions, which came out at 83.5%. Citing a standard and the outcome share a cause; this is not the effect of naming it.
concentrated
78% of these disputes involved pharmacy alone (n=164, 83.5% overturned), so the headline figure for migraine is largely that pairing.
The trend, with its era
computedHover the chart for a year’s counts. Series stops at 2025 — report year 2026 uses a different category vocabulary.
What reviewers relied on
3 validated codesCalifornia requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.
| What the reviewer relied on | In overturns | In upholds |
|---|---|---|
| the FDA label or approval status | 50%n=174 | 46%n=37 |
| a standardised level-of-care instrument | 0%n=174 | 0%n=37 |
| a California statutory definition | 0%n=174 | 0%n=37 |
Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.
Authorities named in this class
computed- FDA83.5%103
- American Headache Society78.4%74
- American Academy of Neurology—14
- National Institutes of Health—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
- Pharmacy83.5%164
- Pain Management80.6%31
- Diagnostic imaging & screening—7
- Neurosurgery—3
- Electro, thermal & radiofrequency—2
- Alternative treatment—1
- Diagnostic & physician evaluation—1
- Ear, nose & throat procedures—1
The specific treatments inside this class
below n=30, no rate is claimed- Migraine Rx83.7%123
- Botox Injection85.3%34
- Nerve Block—25
- Other—10
- MRI—6
- Pain Medication—4
- Biologics—2
- Radiofreq Ablat—2
By review type
computed- Medical Necessity82.1%168
- Experimental/Investigational83.7%43
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.