Cardiac Rx denials at external review

• concentrated

  49% of these disputes involved endocrine & metabolic alone (n=35, 34.3% overturned), so the headline figure for cardiac rx is largely that pairing.

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.

• American College of Cardiology—15
• FDA—12
• American Heart Association—8

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.

• Endocrine & metabolic34.3%35
• Cardiac & circulatory40.6%32
• Genetic disease—3
• Blood disorders—1
• Cancer—1

Browse all condition classes · Pick your own pair

• High Cholesterol34.4%32
• Other—11
• Coronary Artery Disease—6
• Cardiac/Heart Prob—5
• Arrhythmia/Irregular Heart Rhythm—4
• Congestive Heart Failure—3
• Hypertension—3
• Cardiomyopathy—2

• Medical Necessity35.3%68
• Experimental/Investigational—4

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.