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Everything here is free to read, and nothing here is a claim about your case. Built from California’s published records and modified by us — not official government data. How these numbers were made.

Claim Appeal Data
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Treatment class · category · California

Skilled nursing & inpatient rehab denials at external review

When a California health plan denied care in the skilled nursing & inpatient rehab class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.

23.9%

Overturned
32 of 134
Era
2021-2025
Jurisdiction
California DMHC IMR
Published class
Rehab/Svcs SNF Inpt
Median days to decision
23
All years
24.6% of 517
32 overturned102 upheld

What stands out here

computed from this class

  • among the lowest

    At 23.9%, this is the lowest overturn rate of the 22 treatment classes carrying one — one of the few where reviewers more often agreed with the plan than not.

  • falling

    It has fallen over the published record: 40.0% in 2008 against 18.9% in 2023. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.

The trend, with its era

computed
0%25%50%75%100%SB 1410 field mandate18.9%20082023Share of decisions overturning the health plan · years below n=30 omitted

Hover the chart for a year’s counts. Series stops at 2025 — report year 2026 uses a different category vocabulary.

What reviewers relied on

3 validated codes

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.

What the reviewer relied onIn overturnsIn upholds
the FDA label or approval status0%n=320%n=102
a standardised level-of-care instrument0%n=320%n=102
a California statutory definition0%n=320%n=102

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.

Authorities named in this class

computed
  • American Psychiatric 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.

By condition

computed
  • Overturned — the reviewer did not sustain the denial
  • Upheld — the reviewer sustained the denial
  • Cardiac & circulatory24.2%33
  • Orthopedic & musculoskeletal—29
  • Trauma & injuries—22
  • CNS & neuromuscular—15
  • Endocrine & metabolic—6
  • Infectious disease—5
  • Respiratory—5
  • Cancer—4

Browse all condition classes · Pick your own pair

The specific conditions inside this class

below n=30, no rate is claimed
  • Stroke/ CVA—25
  • Other—17
  • Bone Fracture/Break—11
  • Auto Accident—10
  • Brain Injury/Concussion—8
  • Back Pain—6
  • Cardiac/Heart Prob—4
  • Amputation—3

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.