FREE TO READ

Everything here is free to read, and nothing here is a claim about your case. Built from California’s published records and modified by us — not official government data. How these numbers were made.

Claim Appeal Data
Explore

Review type · 2021-2025 · California

Three questions, not one

California sorts every Independent Medical Review into one of three types, and each puts a different question to the reviewer. Reading them as one pool averages away the largest structural difference in this data.

  • Overturned — the reviewer did not sustain the denial
  • Upheld — the reviewer sustained the denial

Where the reviewers disagree with each other

published nowhere else

Experimental/investigational cases are decided by a panel of three, and the published record gives the vote. 54.5% of those panels split 2–1 — 1,053 of 1,931 in 2021-2025. A dissent is more common than agreement on this question.

Medical-necessity cases are decided by a single reviewer, so no comparable number exists for them. This is not a claim that one type is decided better than the other; it is the only place in the published record where a reviewer’s disagreement with another reviewer is visible at all.

These are the reviewer’s question, not the plan’s reason. The published record does not reliably state why a plan denied — it states the ground on which the reviewer resolved the dispute. Nothing here is a classification of insurer behaviour, and building one from this text would mean inventing the plan’s half of an argument that was never published. How these numbers were made.

Every rate here counts only denials appealed all the way to independent review. Fewer than 1% of denials are appealed internally at all, so a share on this page is not the share of denials that are wrong — it is the share of contested ones that reviewers did not sustain. California only, and only plans the state regulates: not self-funded employer plans, Medicare or Medicaid.

Free help. The California DMHC Help Center files an Independent Medical Review at no cost — 1-888-466-2219, dmhc.ca.gov. You do not need us or a lawyer to reach it.