MRI denials at external review

• most-cited standard

  Reviewers named American College of Rheumatology more than any other standard here — 145 decisions, which came out at 54.5%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

• concentrated

  59% of these disputes involved orthopedic & musculoskeletal alone (n=171, 52.0% overturned), so the headline figure for mri is largely that pairing.

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.

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.

• American College of Rheumatology54.5%145
• NCCN—4
• FDA—1
• MCG / Milliman—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.

• Orthopedic & musculoskeletal52.0%171
• Genitourinary & kidney43.3%30
• CNS & neuromuscular—23
• Cancer—15
• Cardiac & circulatory—10
• Digestive & GI—8
• Prevention & wellness—6
• Ear, nose & throat—4

Browse all condition classes · Pick your own pair

• Back Pain46.3%41
• Other57.1%35
• Knee Problem/Pain50.0%30
• Shoulder Problem/Pain—23
• Female Breast Dis/Lump/Cyst—17
• Neck Problem/Pain—16
• Vertebral Disc Prob—15
• Breast—8

• Medical Necessity52.9%278
• Experimental/Investigational—13

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.