Acute inpatient medical denials at external 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.

• LOCUS family—3
• IDSA—2
• NCCN—2
• American Academy of Neurology—1
• American College of Cardiology—1
• American Diabetes Association—1
• American Heart Association—1
• Medicare / CMS—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.

• Trauma & injuries—17
• Cardiac & circulatory—14
• CNS & neuromuscular—12
• Orthopedic & musculoskeletal—11
• Cancer—10
• Genitourinary & kidney—10
• Infectious disease—10
• Digestive & GI—9

Browse all condition classes · Pick your own pair

• Other—17
• Brain Injury/Concussion—8
• Hernia—5
• Bacterial Infection—4
• Viral Infection—4
• Auto Accident—3
• Breathing Problem—3
• Chest Pain—3

• Medical Necessity61.5%122
• Urgent Care—2

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.