Treatment class · category · California

Ear, nose & throat procedures denials at external review

When a California health plan denied care in the ear, nose & throat procedures class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.

76.2%

Overturned: 144 of 189
Era: 2021-2025
Jurisdiction: California DMHC IMR
Published class: Ear-Nose-Thro Proc
Median days to decision: 43
All years: 51.2% of 488

144 overturned45 upheld

What stands out here

computed from this class

the question matters
The outcome turns on which question was put to the reviewer: 82.3% on medical necessity (n=141) against 58.3% on experimental/investigational (n=48) — a gap of 24 points inside the same treatment class.
rising
It has risen over the published record: 23.5% in 2017 against 82.7% 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.
concentrated
81% of these disputes involved ear, nose & throat alone (n=154, 76.0% overturned), so the headline figure for ear, nose & throat procedures is largely that pairing.

The trend, with its era

computed

Hover 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 codes

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.

What the reviewer relied on	In overturns	In upholds
the FDA label or approval status	13%n=144	13%n=45
a standardised level-of-care instrument	0%n=144	0%n=45
a California statutory definition	0%n=144	2%n=45

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

FDA—24

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

Ear, nose & throat76.0%154
CNS & neuromuscular83.9%31
Digestive & GI—1
Endocrine & metabolic—1
Infectious disease—1
Orthopedic & musculoskeletal—1

Browse all condition classes · Pick your own pair

The specific conditions inside this class

below n=30, no rate is claimed

Sinusitis90.3%93
Apnea/Sleep Apnea—28
Other—13
Deviated Septum—12
Hearing Problem/Loss—11
Nasal Air Obstruct—10
Rhinitis—9
Tonsillitis—3

By review type

computed

Medical Necessity82.3%141
Experimental/Investigational58.3%48

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.