Treatment class · subcategory · California
Knee Replacement denials at external review
When a California health plan denied care in the knee replacement class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
12.5%
- Overturned
- 4 of 32
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Knee Replacement
- Median days to decision
- 19
- All years
- 26.9% of 93
What stands out here
computed from this classamong the lowest
At 12.5%, this is the lowest overturn rate of the 70 treatment classes carrying one — one of the few where reviewers more often agreed with the plan than not.
By condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Orthopedic & musculoskeletal12.5%32
The specific conditions inside this class
below n=30, no rate is claimed- Knee Problem/Pain—15
- Osteoarthritis—15
- Joint Problem/Pain—1
- Tendon Problem—1
By review type
computed- Medical Necessity—24
- Experimental/Investigational—8
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.