Neuromuscular RX denials at external review

• among the highest

  At 90.0%, this is the 2nd highest overturn rate of the 70 treatment classes with enough decisions to publish one. Reviewers sustained the plan in the remaining 10.0% of disputes.

• most-cited standard

  Reviewers named FDA more than any other standard here — 60 decisions, which came out at 91.7%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

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.

• FDA91.7%60
• American Academy of Neurology—11
• American Psychiatric Association—1
• American Urological 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.

• CNS & neuromuscular90.1%71
• Genetic disease—8
• Immune disorders—1

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• Multiple Sclerosis95.7%46
• ALS—13
• Muscular Dystrophy—6
• Parkinson's Disease—4
• Other—3
• Narcolepsy—2
• Spinal Muscular Atrophy—2
• Autoimmune Disease—1

• Medical Necessity90.7%75
• Experimental/Investigational—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.