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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
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Review type · 2021-2025 · California

Medical Necessity

Is this treatment necessary for this patient?

The service is an accepted treatment and the dispute is about this person's clinical record — documented severity, what has already been tried, whether the level of care matches the presentation. Decided by a single reviewer.

68.5%

of 9,510 medical necessity decisions in 2021-2025 ended with the reviewer not sustaining the denial. All-time, 55.1% of 31,408.

6,516 overturned2,994 upheld

The panel, and its dissents

published nowhere else

1 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 split 2–1 (100.0%) and 0 were unanimous.

  • Panel split 2-1100.0%1
  • Unanimous 3-00.0%0

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 mandate75.2%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
  • Standard70.5%5,129
  • Expedited66.2%4,381

Most-reviewed treatments

computed
  • Pharmacy75.8%3,820
  • Mental Health80.1%1,547
  • Pain Management89.6%694
  • Diagnostic imaging & screening53.4%672
  • Durable medical equipment56.1%533
  • Orthopedic procedures31.3%281
  • Cancer Care58.6%280
  • Reconstructive & plastic procedures45.5%277
  • Autism-related treatment50.3%165
  • Outpatient rehabilitation39.3%150

Most-reviewed conditions

computed
  • Endocrine & metabolic79.9%1,940
  • Mental health76.6%1,745
  • Orthopedic & musculoskeletal60.1%1,585
  • CNS & neuromuscular69.4%689
  • Cancer57.8%467
  • Skin71.3%414
  • Digestive & GI75.6%410
  • Cardiac & circulatory49.4%340
  • Autism spectrum59.2%292
  • Immune disorders68.4%288

Authorities named in this type

computed
  • Overturned — the reviewer did not sustain the denial
  • Upheld — the reviewer sustained the denial
  • FDA77.2%1,906
  • LOCUS family82.1%819
  • American Society of Addiction Medicine79.3%584
  • American Academy of Child and Adolescent Psychiatry77.6%313
  • American College of Rheumatology60.3%239
  • NCCN55.9%202
  • American Diabetes Association67.4%86
  • American Gastroenterological Association82.1%78

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.