Treatment class · subcategory · California
SCP Consult Refer denials at external review
When a California health plan denied care in the scp consult refer class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
66.2%
- Overturned
- 45 of 68
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- SCP Consult Refer
- Median days to decision
- 39
- All years
- 59.2% of 348
What reviewers relied on
3 validated codesCalifornia 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 on | In overturns | In upholds |
|---|---|---|
| the FDA label or approval status | 0%n=45 | — |
| a standardised level-of-care instrument | 2%n=45 | — |
| a California statutory definition | 2%n=45 | — |
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 College of Obstetricians and Gynecologists—1
- American College of Rheumatology—1
- LOCUS family—1
- NCCN—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 & circulatory—13
- Orthopedic & musculoskeletal—11
- Genitourinary & kidney—8
- CNS & neuromuscular—5
- Digestive & GI—5
- Endocrine & metabolic—4
- Mental health—4
- Skin—4
The specific conditions inside this class
below n=30, no rate is claimed- Other—9
- Congenital Heart Dft—7
- Back Pain—4
- Female Infertility—3
- Cardiac/Heart Prob—2
- Irritable Bowel Syndrome—2
- Leukemia—2
- Obesity—2
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.