Treatment class · subcategory · California
Ultrasound denials at external review
When a California health plan denied care in the ultrasound class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
56.2%
- Overturned
- 27 of 48
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Ultrasound
- Median days to decision
- 38
- All years
- 40.9% of 127
Authorities named in this class
computed- American College of Rheumatology—6
- NCCN—5
- American Urological Association—4
- American College of Obstetricians and Gynecologists—3
- American College of Cardiology—2
- American Heart Association—2
- FDA—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
- Cancer—16
- Genitourinary & kidney—9
- Cardiac & circulatory—8
- Pregnancy/Childbirth—4
- Orthopedic & musculoskeletal—3
- Prevention & wellness—3
- Digestive & GI—2
- CNS & neuromuscular—1
The specific conditions inside this class
below n=30, no rate is claimed- Prostate—13
- Female Breast Dis/Lump/Cyst—7
- Not classified—3
- Other—3
- Pregnancy—3
- Abdominal/Stomach Pain—2
- Angina—1
- Breast—1
By review type
computed- Medical Necessity58.8%34
- Experimental/Investigational—14
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.