Treatment class · category · California
Home Health Care denials at external review
When a California health plan denied care in the home health care class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
41.5%
- Overturned
- 17 of 41
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Home Health Care
- Median days to decision
- 30
- All years
- 46.7% of 152
Authorities named in this class
computed- American Academy of Pediatrics—2
- FDA—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
- CNS & neuromuscular—8
- Genetic disease—6
- Autism spectrum—3
- Digestive & GI—3
- Endocrine & metabolic—3
- Orthopedic & musculoskeletal—3
- Cancer—2
- Cardiac & circulatory—2
The specific conditions inside this class
below n=30, no rate is claimed- Other—11
- Autistic Disorder—3
- Apnea/Sleep Apnea—2
- Crohn's Disease—2
- Diabetes—2
- Adenocarcinoma—1
- Auto Accident—1
- Autoimmune Disease—1
By review type
computed- Medical Necessity42.5%40
- Experimental/Investigational—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.
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.