Appeal win rates · California
Home health care: 47% of denials overturned
Only 41 decisions since 2021, so this page leads with all years since 2001. Across all years since 2001: 47% of 153.
Year by year
Show as a table
| Year | Decisions | Overturned |
|---|---|---|
| 2002 | 8 | 38% |
| 2011 | 5 | 100% |
| 2012 | 5 | 60% |
| 2013 | 7 | 43% |
| 2016 | 16 | 56% |
| 2017 | 10 | 50% |
| 2019 | 21 | 52% |
| 2020 | 14 | 36% |
| 2021 | 8 | 25% |
| 2022 | 9 | 44% |
| 2023 | 5 | 60% |
| 2024 | 12 | 50% |
| 2025 | 7 | 29% |
By treatment
| Treatment | All years | Since 2021 |
|---|---|---|
| Skilled nursing visits | 49% of 90 | 40% of 25 |
Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.
Recent decisions
The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.
Upheld Skilled nursing visits · Brain and nerves The physician reviewer found that the patient’s parent has requested authorization and coverage for shift care private duty nursing services. The submitted documentation does not support the medical necessity of the requested services. In this case, the…
The physician reviewer found that the patient’s parent has requested authorization and coverage for shift care private duty nursing services. The submitted documentation does not support the medical necessity of the requested services. In this case, the patient is neurodevelopmentally normal and presents with obstructive sleep apnea (OSA). Pediatric patients who cannot maintain continuous positive airway pressure (CPAP) placement require close observation and caregiver intervention. Furthermore, the medical literature reports that if a patient’s CPAP adherence remains suboptimal, measures to improve adherence should be implemented, such as behavioral modification or treatment of CPAP side effects, and that alternative treatments for OSA should be considered if these measures are ineffective. Given these findings, the requested shift care private duty nursing services are not medically necessary to achieve or maintain age-appropriate growth and development, attain, regain or maintain functional capacity, or improve, support, or maintain the patient’s current health condition. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in pediatrics with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-46009
Overturned Skilled nursing visits · Genetic conditions The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for in-home private duty nursing services. Current medical literature and consensus guidelines support home health care…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for in-home private duty nursing services. Current medical literature and consensus guidelines support home health care, including private duty nursing, for children with complex medical needs and technology dependence. Children with gastrostomy tubes require skilled nursing for tube care, feeding administration, and prompt recognition and management of complications such as dislodgement, infection, or aspiration. Those with refractory epilepsy, as seen in Nicolaides-Baraitser syndrome, are at risk for life-threatening seizures and require close monitoring, rapid intervention, and medication administration, which often exceeds the capabilities of untrained caregivers. The presence of severe intellectual disability, autism, and verbal processing disorder further complicates care, as these children may be unable to communicate symptoms or cooperate with interventions, increasing the risk of adverse events without skilled supervision. In this clinical setting, given the patient’s high risk for life-threatening events and technology dependence, home private duty nursing services are medically necessary to achieve or maintain age-appropriate growth and development, attain, regain, or maintain functional capacity. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-45365
Overturned Inject/ infus · Digestive system Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for total parenteral nutrition. Total parenteral nutrition is appropriate in patients with malnutrition who are unable to maintain nutritional status despite enteral…
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for total parenteral nutrition. Total parenteral nutrition is appropriate in patients with malnutrition who are unable to maintain nutritional status despite enteral means, or who are not able to be fed orally or enterally for various reasons. Additionally, patients with high-output fistula often need the use of total parenteral nutrition, and nutritional optimization is also needed for healing. In this case, the patient has required total parenteral nutrition in the setting of persistent non-operable colocutaneous fistula, limitations on oral intake, and unintentional weight loss of 40 pounds over a few months. The literature supports the use of total parenteral nutrition in such cases. All told, the requested total parenteral nutrition is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-44512
Upheld Other · Autism The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for (1) home health occupational therapy services provided two times per week for at least 45 minutes per visit with a required…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for (1) home health occupational therapy services provided two times per week for at least 45 minutes per visit with a required reevaluation for additional occupational therapy after four weeks and/or (2) home health speech therapy services provided two times perweek for at least 45 minutes per visit with a required reevaluation for additional speech therapy after four weeks. Occupational therapy is backed by peer-reviewed published scientific evidence for the treatment of patients with autism. For occupational therapy to be medically indicated and in accordance with generally accepted standards, a formal evaluation by a licensed therapist is required. Given that the submitted records do not include a recommendation by an occupational therapist for home-based occupational therapy twice weekly, (1) home health occupational therapy services provided two times per week for at least 45 minutes per visit with a required reevaluation for additional occupational therapy after four weeks are not medically necessary for the treatment of this patient. Speech therapy services should be continued as long as the patient continues making developmental language gains, with the need and potential to make further gains. Similarly to occupational therapy services, for speech therapy to be medically indicated and in accordance with generally accepted standards, a formal evaluation that includes a history, observation of behaviors, formal standardized scoring, and recommendation for services by a licensed speech therapist is required. Given that the submitted records did not include a formal speech therapy evaluation by a licensed speech language pathologist recommending services, (2) home health speech therapy services provided two times per week for at least 45 minutes per visit with a required reevaluation for additional speech therapy after four weeks are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-44388
Upheld Skilled nursing visits · Genetic conditions Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for in-home private duty nursing services. While Mulchandani-Bhoj-Conlin syndrome is associated with feeding difficulty among other medical conditions…
Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for in-home private duty nursing services. While Mulchandani-Bhoj-Conlin syndrome is associated with feeding difficulty among other medical conditions, it does not seem to be characterized by progressive or worsening feeding difficulty. In this case, while the patient does have a g-tube and is receiving small amounts of formula through the gastrostomy (g)-tube throughout the day, the patient is able to tolerate a wide variety of solids by mouth without any documented concern for aspiration. All told, the requested in-home private duty nursing services are not medically necessary to achieve or maintain age-appropriate growth and development, attain, regain or maintain functional capacity, or improve, support or maintain the patient’s current health condition. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in pediatrics, pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-44195
Upheld Skilled nursing visits · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for home health nursing services and home health physical therapy services.The submitted documentation does not support the medical…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for home health nursing services and home health physical therapy services.The submitted documentation does not support the medical necessity of the requested services. The records do not demonstrate that the patient has skilled nursing care needs, including wound care, catheterization, gastrostomy tube feeding, or administration of intravenous or complex medications. In addition, the records do not indicate that the patient was recently hospitalized. The records show that the patient has weakness and fatigue, but lack clinical information in terms of the patient’s level of mobility as well as physical examination findings regarding the patient’s motor strength and neurological and musculoskeletal function. The records also lack clinical documentation to support a finding that the patient is unable to leave the home. Overall, an indication for home health physical therapy services is not evident. For these reasons, the requested home health nursing services and home health physical therapy services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-44007
Upheld Other · Immune system Nature of Statutory Criteria/Case Summary: The patient requested reimbursement and prospective authorization and coverage for custodial level of care services at the skilled nursing home. Findings: The physician reviewer found that A review of the record…
Nature of Statutory Criteria/Case Summary: The patient requested reimbursement and prospective authorization and coverage for custodial level of care services at the skilled nursing home. Findings: The physician reviewer found that A review of the record establishes that the patient has been receiving custodial level care in a skilled nursing facility setting. The patient is medically stable and tolerating a regular diet and oral medications. The record indicates that the patient is seeing podiatry, neurology, orthopedics, and urology on an outpatient basis. The patient does not require the level of observation and treatment provided in terms of physician oversight and skilled nursing care. Further, the record reveals that the patient does not require daily skilled nursing services, including complex wound management, tracheostomy care, tube feeding, or the administration of intravenous (IV) medications. The patient is independent with most of his daily activities as well as bed mobility and transfers. The patient can ambulate short distances with set up assistance and a walker. Otherwise, the patient utilizes a manual wheelchair for longer distance mobility and has no upper or lower extremity deficits. The patient may require assistance with mobility and daily activities, but this does not necessitate custodial level of care services at the skilled nursing home. Therefore, the custodial level of care services at the skilled nursing home were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were not and are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN25-43544
Overturned Caregiver services · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for home health visits. Per the patient’s medical records, the patient has a complex medical history and home health aides have…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for home health visits. Per the patient’s medical records, the patient has a complex medical history and home health aides have helped provide medication management, administration, and safety. In this clinical setting, given that home health visits prevent the patient from requiring a higher level of care, such as hospitalization, and help the patient with self-care and activities of daily living (ADLs), the requested services are medically indicated. Therefore, home health visits are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-43235
Upheld Skilled nursing visits · Hormones and metabolism The physician reviewer found that Nature of Statutory Criteria/Case Summary: The 78-year-old female patient has requested authorization and coverage for shift care private duty services. In this case, the records indicate that the patient is at home and…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The 78-year-old female patient has requested authorization and coverage for shift care private duty services. In this case, the records indicate that the patient is at home and receiving care for her type II diabetes mellitus, hyperlipidemia, and hypertension. This primarily requires medication management. These conditions are not complex enough to require continuous nursing care. The patient does not have intensive skilled nursing care needs, including complex wound management, tracheostomy care, bowel and bladder training, tube feeding, or administration of intravenous (IV) medications. She is incontinent of bowel and bladder and requires changing of briefs, but this does not require skilled nursing care. The patient is also non-ambulatory and requires assistance with bed mobility and performing daily activities. While she requires assistance with mobility and her daily activities, this type of care can be provided by someone other than a skilled nurse and does not require skilled nursing care. The patient requires daily assistance and may require intermittent home health services, such as skilled nursing care, however, this does not necessitate shift care private duty nursing care. Therefore, shift care private duty services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-42860
Overturned Skilled nursing visits · Ear, nose and throat The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for continued home health services (certified home health aide for 120 hours per month and skilled services by a…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for continued home health services (certified home health aide for 120 hours per month and skilled services by a registered nurse for care planning for two hours per month). Pediatric-aged patients with chronic complex healthcare needs may require continued skilled home nursing or home health aides. The American Academy of Pediatrics (AAP) recommends such type of care, including access to and receipt of home health care, for children with complex medical problems to remain safely in the home. In this case, the patient has autism and requires substantial support. The records indicate that the patient requires constant supervision for safety, support for all activities of daily living (ADLs) and instrumental ADLs, behavioral management, and assessment of vital signs. The patient's needs, which are due to his underlying autism disorder, are consistent with those of patients with autism level 3, and the type of care may be provided by a home health aide at home with community-based care. The patient's care also requires the monthly review of orders and staff education by a registered nurse as the interventions include behavioral, positioning, and vital sign management. Therefore, continued home health services (certified home health aide for 120 hours per month and skilled services by a registered nurse for care planning for two hours per month), are medically necessary to treat the patient’s condition for any of the following to prolong life, to promote physical and mental health and to ameliorate a behavioral condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-42859
Overturned Skilled nursing visits · Brain and nerves Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement and prospective authorization and coverage for private duty nursing services (up to 72 hours per week). This patient has numerous disabilities as a result of her…
Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement and prospective authorization and coverage for private duty nursing services (up to 72 hours per week). This patient has numerous disabilities as a result of her chromosomal abnormality, as well as conditions such as gastroesophageal reflux disease (GERD), refractory seizures associated with apnea and desaturation, and severe sleep apnea. This list of medical problems is not exhaustive, but these remain the most pressing because of the potential for increased morbidity and possibility of mortality. While the patient’s parents are both trained layperson caregivers, it is neither reasonable nor safe to expect that they will be able to provide everything that this patient needs at all hours of the day. The patient has remained overall stable since receiving up to 72 hours per week of private duty nursing services. Given these findings, the private duty nursing services (up to 72 hours per week) were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-42507
Overturned Skilled nursing visits · Autism Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for continued home health services (certified home health aide for 120 hours per month and skilled services by a registered nurse for care planning for…
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for continued home health services (certified home health aide for 120 hours per month and skilled services by a registered nurse for care planning for two hours per month). Pediatric-aged patients with chronic complex healthcare needs may require continued skilled home nursing. Patients needing skilled nursing care include those that require respiratory assessments and treatment of respiratory distress, monitoring for seizures, and managing gastrostomy feeds. Home nursing care is recommended for children with complex medical problems so that they may remain safely in the home. Some patients may require in-home care that does not require the skill set of a registered nurse. This includes patients who need supervision due to safety concerns, help with activities of daily living and other clinical supports. In this case, the patient has cognitive impairments related to his diagnosis of autism. He requires constant supervision and support for all daily activities. The patient’s requirements for assistance with activities of daily living and monitoring for safety fit closely with custodial care, which may be provided by a home health aide at home in a community-based setting. Home health aide care is typically supervised by a registered nurse, who will review the clinical status of the patient and form a treatment plan. In this clinical setting, given that current medical literature supports the provision of a home health aide, considered an in-home support, the requested services are medically indicated. Therefore, continued home health services (certified home health aide for 120 hours per month and skilled services by a registered nurse for care planning for two hours per month) are medically necessary to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Case MN24-41694
What these numbers mean
- These are decisions by independent doctors in California’s Independent Medical Review, run by the Department of Managed Health Care for the plans it regulates. They show how past denials ended, not the odds for any one case.
- “Overturned” means the reviewer sided with the patient and the plan had to cover the care. Only denials that reached independent review are counted.
- Plans in other states, and self-funded employer plans, use other independent reviewers; their results aren’t in this data.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, California Health and Human Services Open Data Portal, updated June 1, 2026. 42,749 decisions from 2001 to 2026 (2026 partial).