Treatment class · subcategory · California
Prosthesis denials at external review
When a California health plan denied care in the prosthesis class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
53.3%
- Overturned
- 16 of 30
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Prosthesis
- Median days to decision
- 41
- All years
- 51.1% of 94
Authorities named in this class
computed- American Urological Association—2
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.
By condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Orthopedic & musculoskeletal—14
- CNS & neuromuscular—4
- Cardiac & circulatory—3
- Genitourinary & kidney—3
- Cancer—2
- Genetic disease—2
- Endocrine & metabolic—1
- Trauma & injuries—1
The specific conditions inside this class
below n=30, no rate is claimed- Amputation—11
- Other—6
- Stroke/ CVA—3
- Erectile Dysfunction—2
- Muscular Dystrophy—2
- Auto Accident—1
- Bone—1
- Diabetes—1
By review type
computed- Medical Necessity—21
- Experimental/Investigational—9
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.