Treatment class · subcategory · California
Antibiotics denials at external review
When a California health plan denied care in the antibiotics class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
67.6%
- Overturned
- 25 of 37
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Antibiotics
- Median days to decision
- 26
- All years
- 41.6% of 202
Authorities named in this class
computed- FDA—6
- American Gastroenterological Association—2
- IDSA—2
- American Society of Clinical Oncology—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 condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Digestive & GI—14
- Infectious disease—12
- Cardiac & circulatory—2
- Endocrine & metabolic—2
- Genitourinary & kidney—2
- Ear, nose & throat—1
- Immune disorders—1
- Respiratory—1
The specific conditions inside this class
below n=30, no rate is claimed- Bacterial Infection—12
- Irritable Bowel Syndrome—7
- Other—7
- Cystic Fibrosis—2
- Hypertension—2
- Cyst—1
- Hemmorhoids—1
- Infection—1
By review type
computed- Medical Necessity73.5%34
- Experimental/Investigational—3
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.