Treatment class · subcategory · California
GERD Procedure denials at external review
When a California health plan denied care in the gerd procedure class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
40.5%
- Overturned
- 17 of 42
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- GERD Procedure
- Median days to decision
- 39
- All years
- 39.1% of 64
Authorities named in this class
computed- FDA—8
- American Gastroenterological 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.
By condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Digestive & GI40.5%42
The specific conditions inside this class
below n=30, no rate is claimed- GERD/Reflux Disease40.0%40
- Gallbladder Problem—1
- Hernia—1
By review type
computed- Experimental/Investigational37.8%37
- Medical Necessity—5
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.