Appeal win rates · California
Medical transportation: 55% of denials overturned
Only 28 decisions since 2021, so this page leads with all years since 2001. Across all years since 2001: 55% of 66.
Year by year
Show as a table
| Year | Decisions | Overturned |
|---|---|---|
| 2017 | 6 | 67% |
| 2018 | 11 | 36% |
| 2019 | 9 | 56% |
| 2020 | 12 | 50% |
| 2021 | 9 | 56% |
| 2024 | 9 | 56% |
By treatment
| Treatment | All years | Since 2021 |
|---|---|---|
| Emergency transport | 66% of 32 | 8 decisions |
| Non-emergency medical transport | 42% of 31 | 19 decisions |
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.
Overturned Amb non emerg transport BLS · Mental health The physician reviewer found that a patient has requested authorization and coverage for non‑emergent psychiatric transportation services. The patient has severe major depressive disorder with psychotic features and is receiving Spravato for…
The physician reviewer found that a patient has requested authorization and coverage for non‑emergent psychiatric transportation services. The patient has severe major depressive disorder with psychotic features and is receiving Spravato for treatment‑resistant depression. According to the medical records, Spravato impairs the patient’s ability to drive, and the patient is unable to safely use public transportation or walk long distances after treatment. In this context, arranged transportation is clinically appropriate to ensure safe access to care. The requested services are consistent with accepted standards of mental health treatment, appropriate in scope and duration, and not primarily for convenience. Therefore, the requested non‑emergent psychiatric transportation services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the 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 psychiatry 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 MN26-46964
Overturned Emergency transport · Heart and circulation Nature of Statutory Criteria/Case Summary: A patient’s representative has requested reimbursement for air ambulance services. The records indicate that this patient was transported via air ambulance. The patient was accepted for continued care and follow-up…
Nature of Statutory Criteria/Case Summary: A patient’s representative has requested reimbursement for air ambulance services. The records indicate that this patient was transported via air ambulance. The patient was accepted for continued care and follow-up treatment for diagnoses including advanced-stage lung cancer, septic shock, congestive heart failure, and bronchospasm. Patients with septic shock encounter a significantly increased risk of morbidity, making adequate and timely care critical for improving patient health outcomes. One study noted that “Septic shock is usually challenging to manage due to its variety of clinical characteristics and physiologic dynamics, affecting the outcomes.” The combination of septic shock and respiratory failure in patients with underlying lung cancer and a history of pneumonectomy further complicates management, which requires care in a multidisciplinary and specialized intensive care unit. Another study found that immediate access to advanced critical care services to optimize outcomes is essential for high-risk patients. The records indicate that this patient had a history of lung cancer and pneumonectomy. The patient received air ambulance transportation services given the additional presentation of septic shock, congestive heart failure, and bronchospasm. In this clinical setting, the air ambulance transportation services were appropriate and consistent with the recommendations in the medical literature. In the absence of the air ambulance transportation services, the patient’s health would have been placed in serious jeopardy. Therefore, the medical services were emergency services as defined by California law. Final Result: The reviewer determined that the services at issue services were emergency services 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 emergency 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 UR25-43526
Upheld Non-emergency medical transport · Immune system The physician reviewer found that a patient has requested reimbursement for air ambulance services.The records state that this patient sustained a brain injury. Given the acute change in the patient’s neurological status and the complexity of medical issues…
The physician reviewer found that a patient has requested reimbursement for air ambulance services.The records state that this patient sustained a brain injury. Given the acute change in the patient’s neurological status and the complexity of medical issues, the patient required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient also sustained a decline in the level of function and mobility. Thus, treatment in an intensive rehabilitation therapy program for at least three hours a day and five days a week, or 15 hours over seven consecutive days, was indicated. However, the acute inpatient rehabilitation admission could have been provided at another acute inpatient rehabilitation facility or program that was significantly closer. There is a lack of medical literature supporting that neurorehabilitation at the receiving facility provides superior outcomes compared to other acute inpatient rehabilitation programs. Therefore, air ambulance services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 MN25-45390
Overturned Non-emergency medical transport · Genetic conditions The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for air and associated ground ambulance transportation services. In this case, a review of the medical records reveals that the patient’s…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for air and associated ground ambulance transportation services. In this case, a review of the medical records reveals that the patient’s providers indicated that fixed-wing air ambulance and associated ground ambulance transportation were required to reduce the likelihood of worsening even further the patient’s pain, difficulty speaking, moving, and breathing, as well as reducing the chances of lifelong damage to the patient’s spinal cord. The records establish that the patient was significantly medically compromised and required medical surveillance and attention mandating a shortened transport to the destination due to the risk of seizures, further neurological decline, potential irreversible neurological damage, and potentially life-threatening consequences. Thus, the air and associated ground ambulance transportation services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were 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 neurological surgery 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 MN25-43625
Overturned Non-emergency medical transport · Brain and nerves Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for air and ground ambulance transportation services. This patient suffered a cardiac arrest with anoxic brain injury. The records reflect that the patient’s neurological status…
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for air and ground ambulance transportation services. This patient suffered a cardiac arrest with anoxic brain injury. The records reflect that the patient’s neurological status was gradually improving, evidenced by the presence of spontaneous movement and response to stimuli. These factors predicted a strong chance of a good neurologic outcome for the patient if treated appropriately. Early, intensive, and specialized rehabilitation programs have been shown to markedly improve functional outcomes for patients with anoxic brain injury. Furthermore, patients who experience out-of-hospital cardiac arrests are in a critical state. The medical literature supports the need to transport patients in such cases via ambulance, both air and ground, to an appropriate rehabilitation program for treatment. Here, the patient was appropriately transported to a specialized neurological rehabilitation program via ground and air ambulance for treatment. All told, the air and ground ambulance transportation services at issue were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 emergency 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 MN25-43430
Upheld Non-emergency medical transport · Injury Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for non-emergency air ambulance transportation. Aeromedical transport via fixed-wing or rotary-wing aircraft allows for the transport of critically ill patients with ongoing…
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for non-emergency air ambulance transportation. Aeromedical transport via fixed-wing or rotary-wing aircraft allows for the transport of critically ill patients with ongoing needs for cardiac monitoring, mechanical ventilation, infusion pumps, and suction pumps. Therefore, aeromedical transport should be considered when limitations of ground transport interfere with patient care. Fixed-wing airplanes are used for distances greater than 200 miles for the four main types of transport, which include scene response, transfers, specialty care, and evacuation. Patient acuity, adverse events potential, neurological status, and airway management/oxygen must be considered in fixed-wing air ambulance transport. The patient’s medical records reflect improvement to a Rancho Los Amigos level 6 from a level 3. This means that the patient was confused without agitation and more aware of the environment. The discharge summary states that the patient was alert, well-appearing, and in no distress. The patient was oriented to person, place, and time with normal mood and affect. The patient had normal respirations. Labs prior to discharge demonstrated normal electrolytes and renal function. The nursing note shows that prior to discharge, the patient did not have a Foley or a peripherally inserted central catheter (PICC) line, and she was on room air without oxygen needs. Additionally, the nursing note indicates the patient could ambulate to a bedside commode. Taking all these factors into account, the patient was clinically stable from a neurological and cardiopulmonary standpoint and not critically ill at the time of transport. The patient did not require airway management and did not have oxygen needs. She was not receiving special intravenous (IV) infusions. The medical record also does not reflect autonomic dysfunction or other vital sign instability often seen in the traumatic brain injury and spinal cord injury (SCI) trauma patient populations that would support an indication for air ambulance transport. All told, the non-emergency air ambulance transportation was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was 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 with subspecialty certification in brain injury 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 MN24-43420
Overturned Non-emergency medical transport · Kidney and urinary The physician reviewer found that A 58-year-old male with a history of cirrhosis related to metabolic dysfunction associated with steatotic liver disease, with acute decompensated chronic liver failure related to pneumonia has requested reimbursement for…
The physician reviewer found that A 58-year-old male with a history of cirrhosis related to metabolic dysfunction associated with steatotic liver disease, with acute decompensated chronic liver failure related to pneumonia has requested reimbursement for non-emergency air ambulance services. The records provided for review document that this patient required a liver transplant. However, the patient was not deemed a candidate for a liver transplant at the sending facility. The patient was a potential transplant candidate at the receiving facility, so he was appropriately transferred to that facility. The patient required critical care services across state lines over a long distance, so air transport was medically necessary. Therefore, the non-emergency air ambulance services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 internal medicine with subspecialty certifications in gastroenterology and transplant hepatology 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 MN24-42793
Upheld Non-emergency medical transport · Injury The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for non-emergency air, and associated ground ambulance, transportation services. The records indicate that the patient suffered a significant…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for non-emergency air, and associated ground ambulance, transportation services. The records indicate that the patient suffered a significant traumatic brain injury (TBI) due to a motor vehicle accident. He also suffered multiple fractures and a hemothorax and required intubation and placement of a tracheostomy. Given the extent of the patient’s injuries and TBI, acute inpatient rehabilitation was medically appropriate for the patient’s condition. He received acute inpatient rehabilitation at an out-of-state facility. However, acute inpatient rehabilitation could have been provided at a closer and equivalent hospital. There is a lack of medical literature indicating that acute inpatient rehabilitation at the facility selected provides superior outcomes compared to other acute inpatient rehabilitation hospitals. For these reasons, the non-emergency air, and associated ground ambulance, transportation services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 MN24-42388
Overturned Emergency transport · Child health Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for air ambulance transportation. Air ambulance transport involves the use of fixed-wing or rotary-wing aircraft to transfer a patient from one location to another…
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for air ambulance transportation. Air ambulance transport involves the use of fixed-wing or rotary-wing aircraft to transfer a patient from one location to another. Generally accepted indications for air ambulance transport may be divided into medical and trauma categories. Medical indications include acute cardiac emergencies, acute surgical emergencies, acute neurological emergencies that require intervention, acute vascular emergencies, conditions that require hyperbaric oxygen, and critically ill patients requiring intensive care during transport. The list of trauma indications is rather long, but includes serious burns, hemodynamic instability, spinal cord injuries, multisystem injuries, penetrating trauma, limb-threatening injuries, near-drowning, and major pelvic fracture. Absolute contraindications to air transport would include weather, uncontrollably violent patients, and patients contaminated with hazardous materials. Relative contraindications would include patients not easily managed in the tight quarters of the aircraft and patients that may not be able to tolerate altitude changes. The management of spina bifida, or myelomeningocele, typically involves surgical intervention within 48 hours of birth, although fetal surgery has been implemented in a number of institutions. The goal is to prevent ascending infection and any further deficits. It is essential to understand the extent of the defect with baseline imaging studies. In this case, the patient was born via emergency cesarean section due to a prolapsed umbilical cord, with the neural tube defect discovered at the time of delivery. Prenatal evaluation had failed to identify its presence. As the nature and extent of the defect was unknown until the time of delivery, the resources at the hospital where the patient was delivered were insufficient to adequately diagnose and manage her condition. Given the need for urgent transfer to a higher level of care and as air transport was the most expeditious and safe alternative, with least likelihood of exacerbating the patient’s condition, the service at issue was medically indicated. Therefore, air ambulance transportation was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was 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 pediatrics with sub-specialty certification in pediatric critical care 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 MN24-41609
Upheld Non-emergency medical transport · Injury The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for non-emergency air ambulance. The records indicate that this patient was involved in a motor vehicle accident and suffered a…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for non-emergency air ambulance. The records indicate that this patient was involved in a motor vehicle accident and suffered a traumatic brain injury (TBI) with left frontal intraparenchymal hemorrhage, ganglia infarcts, and diffuse axonal injury. The patient’s other injuries included a right clavicle fracture and right orbital and maxillary sinus fractures. She also sustained injuries to the esophagus with glass shards. The patient required placement of an external ventricular drain (EVD) and mechanical ventilation with intubation, both of which were ultimately discontinued. The patient was in a minimally conscious state per an evaluation by neurology. She was discharged to a pediatric skilled nursing and subacute facility for continued care. The patient was subsequently admitted to the hospital due to feeding intolerance with multiple episodes of vomiting. The patient was receiving gastrostomy tube (G-tube) feeding and was noted to be having bowel movements, likely due to neurogenic dysmotility. The patient was transitioned off a ketogenic diet and was tolerating feeding at the time of her discharge. The patient was then admitted to an acute inpatient rehabilitation facility for neurorehabilitation given her TBI, which required non-emergency air ambulance transportation. In this case, while the acute inpatient rehabilitation for the patient’s TBI may be considered medically necessary, the non-emergency air ambulance transportation cannot be. There is no medical literature indicating that the acute inpatient rehabilitation facility selected provides outcomes that are significantly better than acute inpatient rehabilitation facilities that are more local and do not require air ambulance transportation. For these reasons, the non-emergency air ambulance was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 MN24-41378
Upheld Non-emergency medical transport · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: The representative of the patient has requested reimbursement for an air ambulance. Air ambulance transportation was not medically necessary to treat the patient's medical condition…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The representative of the patient has requested reimbursement for an air ambulance. Air ambulance transportation was not medically necessary to treat the patient's medical condition as the patient’s transfer did not require emergent or critical care for the treatment of her condition. Per a review of the current medical literature, fixed-wing aeromedical transport is indicated for critically ill patients who need constant medical attendance and monitoring. The medical records reported that the patient was initially admitted to a hospital in Louisiana for fungal peritonitis and septic shock. Upon discharge from the transferring facility, the patient showed improvements hemodynamically and was no longer on vasopressor support prior to transportation. The medications listed for transportation included pain medication, bronchodilators, antibiotics, Ursodiol, octreotide, Benadryl, and loperamide, but there was no evidence of any critical care medications. The medical records indicated that the patient required one liter of supplemental oxygen via nasal cannula but did not require vasoactive support or continuous intravenous (IV) infusions that would need continuous monitoring. The medical records fail to demonstrate evidence that the transfer to a facility in California was required for specialized, advanced care or because standards of treatment for the patient’s medical conditions were not available. The medical records document that the main reason for the transfer was to establish continuity of care near the patient’s support system. Overall, there is a lack of medical evidence supporting that the patient required critical care for air ambulance transport. Given these findings, the air ambulance was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 pulmonary diseases with subspecialty certification in critical care 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 MN24-41276
Upheld Non-emergency medical transport · Injury The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for non-emergency air, and associated ground ambulance, transportation services. At issue is whether the non-emergency air, and associated…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for non-emergency air, and associated ground ambulance, transportation services. At issue is whether the non-emergency air, and associated ground ambulance, transportation services were medically necessary for the treatment of this patient.The records indicate that this patient was admitted to the hospital after presenting to the emergency department with intracranial hemorrhage and fractures to the right femur, first rib, T1 transverse, and clavicle due to a motor vehicle accident. The patient required placement of a ventriculostomy and then a left decompressive hemicraniectomy as well as intramedullary nail fixation of the right femur. He also required mechanical ventilation with placement of a tracheostomy as well as placement of a percutaneous endoscopic gastrostomy (PEG) tube. The patient was transferred to a long-term acute care facility, where he was extubated. The records show the patient underwent a cranioplasty and replacement of his bone flap. The patient was noted to require moderate to maximum assistance with bed mobility and transfers. Given the complexity of the patient’s medical condition, he was found to be an appropriate candidate for acute inpatient rehabilitation with the oversight of a rehabilitation physician and rehabilitation nursing care. The patient required intensive therapies given his significant decline in function and mobility. Thus, admission for acute inpatient rehabilitation services was indicated. However, acute inpatient rehabilitation services could have been provided for the patient’s brain injury at the University of California at Irvine Medical Center. There is a lack of medical evidence supporting the medical necessity of transporting the patient to Craig Hospital in Colorado, or that this care is superior to the rehabilitation services provided at the University of California at Irvine Medical Center. Additionally, there are at least four facilities in Southern California that offer acute inpatient rehabilitation that would have also been able to provide adequate services for the patient. Given these findings, the non-emergency air and associated ground ambulance, transportation services provided were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 MN23-40254
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).