Treatment class · category · California
Cancer Care denials at external review
When a California health plan denied care in the cancer care class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
52.6%
- Overturned
- 255 of 485
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Cancer Care
- Median days to decision
- 17
- All years
- 43.6% of 1,620
What stands out here
computed from this classthe question matters
The outcome turns on which question was put to the reviewer: 58.6% on medical necessity (n=280) against 44.4% on experimental/investigational (n=205) — a gap of 14 points inside the same treatment class.
rising
It has risen over the published record: 25.0% in 2004 against 55.4% in 2025. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.
most-cited standard
Reviewers named NCCN more than any other standard here — 241 decisions, which came out at 49.8%. Citing a standard and the outcome share a cause; this is not the effect of naming it.
The trend, with its era
computedHover the chart for a year’s counts. Series stops at 2025 — report year 2026 uses a different category vocabulary.
What reviewers relied on
3 validated codesCalifornia 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.
| What the reviewer relied on | In overturns | In upholds |
|---|---|---|
| the FDA label or approval status | 13%n=255 | 23%n=230 |
| a standardised level-of-care instrument | 0%n=255 | 0%n=230 |
| a California statutory definition | 0%n=255 | 0%n=230 |
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.
Authorities named in this class
computed- NCCN49.8%241
- FDA39.8%83
- American Urological Association—23
- American Academy of Dermatology—2
- American College of Rheumatology—2
- American Society of Clinical Oncology—1
- MCG / Milliman—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
- Cancer52.1%476
- CNS & neuromuscular—4
- Genitourinary & kidney—2
- Skin—2
- Endocrine & metabolic—1
The specific conditions inside this class
below n=30, no rate is claimed- Prostate43.7%142
- Breast53.5%101
- Brain55.6%36
- Lung—21
- Other—20
- Lymphoma—17
- Colon—14
- Skin—12
By review type
computed- Medical Necessity58.6%280
- Experimental/Investigational44.4%205
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.