Multiple Sclerosis denials at external review

• most-cited standard

  Reviewers named FDA more than any other standard here — 58 decisions, which came out at 93.1%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

California 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.

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.

• FDA93.1%58
• American Academy of Neurology—18

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.

• Pharmacy90.1%81
• Durable medical equipment—4
• Special procedures—2
• Acute inpatient medical—1
• Neurosurgery—1
• Pain Management—1
• Outpatient rehabilitation—1
• Skilled nursing & inpatient rehab—1

Browse all treatment classes · Pick your own pair

• Neuromuscular RX95.7%46
• Biologics—21
• IVIG Therapy—8
• Other—5
• Hormones—2
• Stem Cell Transplant—2
• Wheelchair—2
• Anti-inflammatories—1

• Medical Necessity85.1%87
• Experimental/Investigational—5

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.