Treatment class · subcategory · California
Breast reduction denials at external review
When a California health plan denied care in the breast reduction class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
67.7%
- Overturned
- 21 of 31
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Breast reduction
- Median days to decision
- 49
- All years
- 56.4% of 165
Authorities named in this class
computed- American Society of Plastic Surgeons—13
- WPATH—2
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
- Genitourinary & kidney—14
- Orthopedic & musculoskeletal—8
- Endocrine & metabolic—6
- Mental health—2
- Skin—1
The specific conditions inside this class
below n=30, no rate is claimed- Female Breast Dis/Lump/Cyst—14
- Back Pain—5
- Other—4
- Gender Dysphoria—2
- Diabetes—1
- Excess Skin—1
- Gynecomastia—1
- Muscle Spasms—1
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.