Condition class · category · California
Post-surgical complications denials at external review
When a California health plan denied care for post-surgical complications and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
31.2%
- Overturned
- 10 of 32
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Post Surgical Comp
- Median days to decision
- 40
- All years
- 26.0% of 154
What stands out here
computed from this classamong the lowest
At 31.2%, this is the lowest overturn rate of the 24 conditiones carrying one — one of the few where reviewers more often agreed with the plan than not.
Authorities named in this class
computed- American College of Rheumatology—1
- 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
- Reconstructive & plastic procedures—6
- Special procedures—5
- Pharmacy—4
- Diagnostic imaging & screening—3
- General surgery—3
- Durable medical equipment—2
- Orthopedic procedures—2
- Pain Management—2
The specific treatments inside this class
below n=30, no rate is claimed- Hyperbaric O2 Chamb—5
- Pain Medication—4
- Bariatric Surgery—3
- MRI—3
- Other—3
- Breast Augmentation—2
- Admission—1
- Artificial Disc Repl—1
By review type
computed- Medical Necessity—29
- Experimental/Investigational—2
- Urgent Care—1
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.