Respiratory denials at external review

• rising

  It has risen over the published record: 45.2% in 2004 against 63.4% in 2024. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.

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.

• FDA—22
• American Academy of Pediatrics—3
• American College of Rheumatology—3
• MCG / Milliman—3
• American College of Cardiology—1
• American Thoracic Society—1
• NCCN—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.

• Pharmacy68.6%70
• Durable medical equipment—28
• Diagnostic imaging & screening—17
• Acute inpatient medical—9
• Skilled nursing & inpatient rehab—5
• Emergency & urgent care—3
• Preventive health screening—3
• Home Health Care—2

Browse all treatment classes · Pick your own pair

• Asthma Rx69.7%33
• Other—28
• Biologics—11
• Allergy Rx—10
• CT Scan—7
• Admission—6
• Pneumatic Vest—6
• Inpt Admission—4

• Medical Necessity58.7%121
• Experimental/Investigational—17
• Urgent Care—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.