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

Experimental/Investigational

Is this treatment established enough to be a covered benefit at all?

The question moves off the patient and onto the evidence base: published literature, regulatory status, specialty-society guidance. Decided by a panel of three, whose vote is published.

49.5%

of 2,024 experimental/investigational decisions in 2021-2025 ended with the reviewer not sustaining the denial. All-time, 45.4% of 10,445.

1,002 overturned1,022 upheld

The panel, and its dissents

published nowhere else

1,931 of these decisions were made by a panel of three rather than a single reviewer, and the published record gives each panel’s vote. 1,053 split 2–1 (54.5%) and 782 were unanimous.

  • Panel split 2-154.5%1,053
  • Unanimous 3-045.5%782

A dissent is not an error and this is not a claim that either side of a split was right. It is the only place in California’s published record where one reviewer’s disagreement with another is visible, and on this question it is more common than agreement.

The trend

computed
0%25%50%75%100%SB 1410 field mandate53.6%200220052010201520202025Share of decisions overturning the health plan · years below n=30 omitted

Hover the chart for a year’s counts. Series stops at 2025 — report year 2026 uses a different category vocabulary.

Standard against expedited

computed
  • Standard46.8%1,225
  • Expedited53.7%799

Most-reviewed treatments

computed
  • Diagnostic imaging & screening40.9%574
  • Pharmacy59.1%301
  • Pain Management50.6%243
  • Cancer Care44.4%205
  • Durable medical equipment55.5%146
  • Electro, thermal & radiofrequency49.6%125
  • Orthopedic procedures28.1%96
  • Cardiovascular procedures70.0%90
  • General surgery56.5%69
  • Ear, nose & throat procedures58.3%48

Most-reviewed conditions

computed
  • Cancer48.1%424
  • Orthopedic & musculoskeletal36.0%394
  • Cardiac & circulatory56.8%243
  • CNS & neuromuscular74.4%234
  • Endocrine & metabolic54.4%149
  • Digestive & GI44.6%101
  • Genitourinary & kidney39.1%92
  • Immune disorders63.8%58
  • Mental health36.7%49
  • Ear, nose & throat46.5%43

Authorities named in this type

computed
  • Overturned — the reviewer did not sustain the denial
  • Upheld — the reviewer sustained the denial
  • NCCN49.0%249
  • FDA50.6%245
  • American College of Cardiology45.3%64
  • American Heart Association44.8%58
  • American College of Obstetricians and Gynecologists9.7%31
  • American Urological Association—26
  • American College of Rheumatology—21
  • American Academy of Dermatology—12

Free help, first. The California DMHC Help Center files an Independent Medical Review at no cost — 1-888-466-2219, dmhc.ca.gov. It is the same review described on this page. See whether this covers you and what these words mean.

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.