Diagnostic & physician evaluation denials at external review

• rising

  It has risen over the published record: 42.9% in 2002 against 55.6% in 2021. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own 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.

• American College of Obstetricians and Gynecologists—3
• NCCN—3
• American College of Rheumatology—2
• FDA—2
• LOCUS family—2
• American Academy of Child and Adolescent Psychiatry—1
• American Academy of Neurology—1
• American Psychiatric Association—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.

• Cardiac & circulatory—18
• Orthopedic & musculoskeletal—18
• Genitourinary & kidney—14
• Cancer—8
• CNS & neuromuscular—7
• Digestive & GI—6
• Skin—6
• Endocrine & metabolic—5

Browse all condition classes · Pick your own pair

• Other—17
• Congenital Heart Dft—7
• Allergy—5
• Back Pain—4
• Breast—3
• Female Infertility—3
• Autistic Disorder—2
• Blood Clot—2

• Medical Necessity57.1%105
• Experimental/Investigational—6
• Urgent Care—1

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.