Condition class · subcategory · California
Sinusitis denials at external review
When a California health plan denied care for sinusitis and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
86.9%
- Overturned
- 86 of 99
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Sinusitis
- Median days to decision
- 45
- All years
- 59.5% of 185
What stands out here
computed from this classamong the highest
At 86.9%, this is the 7th highest overturn rate of the 72 conditiones with enough decisions to publish one. Reviewers sustained the plan in the remaining 13.1% of disputes.
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 | 2%n=86 | — |
| a standardised level-of-care instrument | 0%n=86 | — |
| a California statutory definition | 0%n=86 | — |
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- FDA—3
- 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.
By treatment
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Ear, nose & throat procedures90.3%93
- Pharmacy—3
- Diagnostic imaging & screening—2
- Reconstructive & plastic procedures—1
The specific treatments inside this class
below n=30, no rate is claimed- Sinus Surgery90.8%76
- Other—16
- Biologics—2
- MRI—2
- Antibiotics—1
- Rhinoplasty—1
- Septoplasty—1
By review type
computed- Medical Necessity88.0%92
- Experimental/Investigational—7
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.