Treatment class · subcategory · California
Inpt Discharge denials at external review
When a California health plan denied care in the inpt discharge class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
12.5%
- Overturned
- 5 of 40
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Inpt Discharge
- Median days to decision
- 22
- All years
- 15.7% of 83
What stands out here
computed from this classamong the lowest
At 12.5%, this is the 2nd-lowest overturn rate of the 70 treatment classes carrying one — one of the few where reviewers more often agreed with the plan than not.
What reviewers relied on
3 validated codesCalifornia 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 | — | 0%n=35 |
| a standardised level-of-care instrument | — | 0%n=35 |
| a California statutory definition | — | 0%n=35 |
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.
By condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Cardiac & circulatory—13
- Orthopedic & musculoskeletal—9
- Trauma & injuries—6
- Endocrine & metabolic—3
- CNS & neuromuscular—2
- Cancer—1
- Genitourinary & kidney—1
- Infectious disease—1
The specific conditions inside this class
below n=30, no rate is claimed- Stroke/ CVA—9
- Bone Fracture/Break—4
- Other—4
- Auto Accident—3
- Amputation—2
- Brain Injury/Concussion—2
- Cardiac/Heart Prob—2
- Diabetes—2
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.