Neurosurgery denials at external review

• among the highest

  At 86.0%, this is the highest overturn rate of the 22 treatment classes with enough decisions to publish one. Reviewers sustained the plan in the remaining 14.0% of disputes.

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.

• FDA—6

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 & neuromuscular90.0%30
• Orthopedic & musculoskeletal—8
• Mental health—5
• Cardiac & circulatory—2
• Trauma & injuries—2
• Cancer—1
• Foot—1
• Skin—1

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• Other—9
• Peripheral Neuropathy—7
• Epilepsy—4
• Complex Regional Pain Synd/RSD—3
• Depression—3
• Migraine—3
• Paralysis—3
• Back Pain—2

• Experimental/Investigational88.2%34
• Medical Necessity—16

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.