Appeal win rates · California
Preventive screenings: 27% of denials overturned
Only 10 decisions since 2021, so this page leads with all years since 2001. Across all years since 2001: 27% of 44.
Recent decisions
The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.
Upheld Childhood immun · Pregnancy and gynecology The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for ABRYSVO prenatal vaccination. Respiratory syncytial virus (RSV) is a significant cause of illness in infants, and maternal…
The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for ABRYSVO prenatal vaccination. Respiratory syncytial virus (RSV) is a significant cause of illness in infants, and maternal vaccination is one strategy to reduce risk. Current guidance recommends a single dose of RSV vaccine during pregnancy in appropriate candidates. In this case, the patient has previously received the RSV vaccine during a prior pregnancy. Clinical guidance does not support repeat vaccination in subsequent pregnancies after prior receipt. Therefore, the requested ABRYSVO prenatal vaccine is not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested medication is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial is upheld. Credentials/Qualifications:The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.
Case MN25-45502
Overturned Other · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for dietary assessment and nutrition counseling. By focusing on portion control, mindful eating, and the incorporation of…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for dietary assessment and nutrition counseling. By focusing on portion control, mindful eating, and the incorporation of nutrient-dense foods, patients can make lasting changes to their dietary habits, ultimately improving their overall health. By providing patients with personalized dietary guidance, nutritional counselors empower individuals to make informed choices that can lead to significant improvements in their overall health. In this clinical setting, given that current medical literature supports the role of nutritional counseling as a preventive means of controlling chronic health conditions, enhancing overall quality of life, reducing the risk of complications, and promoting long-term wellness, the requested services are medically indicated. Therefore, dietary assessment and nutrition counseling are medically necessary for the treatment of this patient. 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 endocrinology, diabetes, and metabolism 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 MN25-43983
Overturned Childhood immun · Prevention Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Bacille Calmette-Guerin (BCG) vaccine for tuberculosis. The medical literature recommends BCG vaccination worldwide, stating, “the BCG vaccine is a…
Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Bacille Calmette-Guerin (BCG) vaccine for tuberculosis. The medical literature recommends BCG vaccination worldwide, stating, “the BCG vaccine is a crucial component of tuberculosis control and is given to more than 100 million newborn babies every year”. Meta-analysis data now shows that infant BCG vaccination effectively protects against all tuberculosis, pulmonary tuberculosis, and death. In situations where potential for significant exposure to tuberculosis is unavoidable, administration is also recommended. Based on the current literature, recommendations, and potential for benefit by administering at this time prior to departure to a high-risk zone, BCG vaccination is indicated and appropriate for this infant and should be administered prior to travel. All told, the requested BCG vaccine for tuberculosis is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 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 MN24-42223
Upheld Adult immunization · Prevention Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for meningitis vaccine. The Centers for Disease Control (CDC) summarizes those at high risk in its meningococcal vaccine recommendation guidelines. In this case…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for meningitis vaccine. The Centers for Disease Control (CDC) summarizes those at high risk in its meningococcal vaccine recommendation guidelines. In this case, the records do not reflect that the patient is in a high-risk adult group that requires vaccination or repeat vaccination. The patient is not documented as being human immunodeficiency virus (HIV) positive, traveling to an area of outbreak, or working with the bacteria. He does not have an absence of a spleen. Current medical literature does not identify sexual orientation and/or practices as risk factors for meningococcal meningitis. In this clinical setting, the requested medication is not medically indicated. Therefore, meningitis vaccine is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is 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 internal 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 MN24-41735
Upheld Adult immunization · Lungs and breathing The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for a respiratory syncytial virus (RSV) vaccine (Beyfortus). The current Centers for Disease Control and Prevention (CDC) Advisory…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for a respiratory syncytial virus (RSV) vaccine (Beyfortus). The current Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommendation for Beyfortus is for administration to infants less than eight months of age born during or entering their first RSV season and for infants and young children from eight months to 19 months at increased risk for severe RSV disease entering their second RSV season. Additional groups recommended to receive Beyfortus when entering their second RSV season include children with severe immunocompromise and children with cystic fibrosis with either severe lung disease or weight-for-length less than the 10th percentile. Furthermore, because of current limitation in supply of the dosing at issue, the CDC and ACIP are recommending prioritizing the available doses of Beyfortus to an even stricter patient population, including patients with underlying medical conditions that place them at highest risk for severe RSV disease. Based on the original ACIP recommendations for administration of Beyfortus, this patient did not meet the criteria for Beyfortus treatment. While she was born prematurely at 32 weeks gestation and was less than 19 months of age at the anticipated start of the RSV season, she does not fall into any of the categories considered to be at risk of severe disease. She did not have a history of severe immunocompromise, severe cystic fibrosis, or hemodynamically significant congenital heart disease. Given these findings, the RSV vaccine (Beyfortus) was not medically necessary for the treatment of the patient. Final Result: The reviewer determined that the medication 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 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 MN24-41192
Upheld Childhood immun · Lungs and breathing Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Synagis (palivizumab) given once monthly during respiratory syncytial virus (RSV) season. As noted by the American Academy of Pediatrics (AAP) and…
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Synagis (palivizumab) given once monthly during respiratory syncytial virus (RSV) season. As noted by the American Academy of Pediatrics (AAP) and American Academy of Pediatrics Bronchiolitis (AAPB), RSV prophylaxis with Synagis (palivizumab) may be appropriate for preterm infants who are in the first year of life at the start of the RSV season and who have chronic lung disease of prematurity to a maximum of five monthly doses. Chronic lung disease of prematurity is defined as infants with gestational age less than 32 weeks and a requirement for greater than 21% oxygen for at least the first 28 days after birth. For infants born during the RSV season, fewer than five monthly doses may be needed to complete the RSV season. In addition, RSV prophylaxis with Synagis (palivizumab) may be appropriate for infants in the RSV season during the second year of life who satisfy the definition of chronic lung disease of prematurity and who continue to require medical support with chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen during the six-month period before the start of the second RSV season, for a maximum of five monthly doses. Based on the available documentation, this patient does not meet the criteria for a diagnosis of chronic lung disease to support an indication for treatment with RSV vaccine Synagis. The patient’s medications are noted to include Flovent HFA, Pulmicort, Xopenex, and Xopenex HFA. The records fail to document that the patient has continued to require medical support with chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen during the six-month period before the start of the second RSV season. Therefore, the requested Synagis (palivizumab) given once monthly during RSV season is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 pediatrics with subspecialty certifications in medical toxicology, and pediatric pulmonology 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 MN22-38148
Upheld Childhood immun · Lungs and breathing The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Synagis (palivizumab) given once monthly during respiratory syncytial virus (RSV) season. As noted by the American…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Synagis (palivizumab) given once monthly during respiratory syncytial virus (RSV) season. As noted by the American Academy of Pediatrics (AAP) and American Academy of Pediatrics Bronchiolitis (AAPB), RSV prophylaxis with Synagis (palivizumab) may be appropriate for preterm infants who are in the first year of life at the start of the RSV season and who have chronic lung disease of prematurity to a maximum of five monthly doses. Chronic lung disease of prematurity is defined as infants with gestational age less than 32 weeks and a requirement for greater than 21% oxygen for at least the first 28 days after birth. For infants born during the RSV season, fewer than five monthly doses may be needed to complete the RSV season. In addition, RSV prophylaxis with Synagis (palivizumab) may be appropriate for infants in the RSV season during the second year of life who satisfy the definition of chronic lung disease of prematurity and who continue to require medical support with chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen during the six-month period before the start of the second RSV season, for a maximum of five monthly doses. Based on the available documentation, this patient does not meet the criteria for a diagnosis of chronic lung disease to support an indication for treatment with RSV vaccine Synagis. The patient’s medications are noted to include Flovent HFA, Pulmicort, Xopenex, and Xopenex HFA. The records fail to document that the patient has continued to require medical support with chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen during the six-month period before the start of the second RSV season. Therefore, the requested Synagis (palivizumab) given once monthly during RSV season is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 pediatrics with subspecialty certifications in medical toxicology, and pediatric pulmonology 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 MN22-38146
Upheld Adult immunization · Infection Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Shingrex shingles vaccination. The submitted documentation does not support the medical necessity of the requested medication. Varicella-zoster virus (VZV)…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Shingrex shingles vaccination. The submitted documentation does not support the medical necessity of the requested medication. Varicella-zoster virus (VZV) infection may cause both a primary infection known as chickenpox and a reactivated infection, from latent VZV in nerve cells, known as Herpes zoster or shingles. The U.S. Food and Drug Administration (FDA) approves the use of Shingrex for the prevention of herpes zoster, or Shingles, in adults aged 50 years or older or in adults aged 18 years or older with immunodeficiency or immunosuppression caused by disease or therapy. Medical literatures note that the vaccine consists of varicella-zoster virus glycoprotein E (gE). In this case, the records reflect that the patient is 46 years of age. The records do not document that the patient is immunocompromised, or that her provider is planning to prescribe medications that will cause the patient to become immunocompromised. While the records note that the provider has prescribed Acyclovir for the patient’s previous infections of recurrent zoster, there is no documentation of a physical examination of the skin that has confirmed these infections. Therefore, a Shingrex shingles vaccination is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 internal 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 MN22-37450
Overturned Adult immunization · Prevention Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gardasil human papillomavirus (HPV) three-dose schedule vaccine. Findings: The patient presents with a history of abnormal pap smear and she is at continued…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gardasil human papillomavirus (HPV) three-dose schedule vaccine. Findings: The patient presents with a history of abnormal pap smear and she is at continued risk of cervical cancer. The Gardasil HPV vaccine series is U.S. Food and Drug Administration (FDA) approved for patients ages 9 through 45 years of age for prevention of cervical cancer caused by multiple HPV types. Per a study, vaccination against HPV is “recommended to prevent new HPV infections and HPV-associated diseases, including some cancers.” This patient may not have been exposed to all the different HPV types thus far, therefore vaccination is still considered protective. Given this support, the requested Gardasil HPV three-dose schedule vaccine is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 obstetrics and gynecology 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 MN21-35543
Overturned Adult immunization · Infection An enrollee has requested authorization and coverage for the Gardasil 9 vaccine series. Updated recommendations of the CDC Advisory Committee on Immunization Practices (ACIP) for vaccination against human papillomavirus (HPV) note that the public health…
An enrollee has requested authorization and coverage for the Gardasil 9 vaccine series. Updated recommendations of the CDC Advisory Committee on Immunization Practices (ACIP) for vaccination against human papillomavirus (HPV) note that the public health benefit of HPV vaccination in all adults greater than 26 years of age is minimal, but that shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 to 45 years, because some persons who are not adequately vaccinated might benefit. In this case, the patient is within the 27 through 45 years age range identified by the ACIP. Furthermore, the updated recommendations of the ACIP state that shared decision-making regarding HPV vaccination is recommended for this population. The patient’s treating provider recommended the Gardasil 9 vaccine series considering the patient’s history of multiple homosexual sex partners, and one PAP smear which demonstrated low-grade squamous intraepithelial lesion (LGSIL) although biopsy was negative and subsequent PAP smears have been negative. This represents shared decision-making. Therefore, the patient meets the ACIP criteria regarding shared decision-making and regarding the recommended age range. Accordingly, the requested Gardasil 9 vaccine series is medically necessary to treat the patient’s medical condition. Final Result: The reviewer determined that the requested medication is medically necessary to treat 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 certification in infectious disease, 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 MN20-33155
Overturned Prev nutrit counsel · Hormones and metabolism Nature of Statutory Criteria/Case Summary: An enrollee requested a one-on-one visit with a nutrition specialist for medical treatment of her diabetes. Findings: The physician reviewer found that the submitted documentation supports the requested services in…
Nature of Statutory Criteria/Case Summary: An enrollee requested a one-on-one visit with a nutrition specialist for medical treatment of her diabetes. Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. This patient has a high BMI and has type 2 diabetes mellitus. Lifestyle interventions and medical nutritional therapy are essential cornerstones of diabetes management. It is standard of care that obese patients with diabetes be referred to individualized medical nutritional therapy as part of diabetes self-management education, especially if they have been unsuccessful in losing weight. A patient with morbid obesity requires individualized medical nutritional therapy. A weight loss of 5% or greater may have significant effect in the outcomes and improvement of diabetes and blood pressure control. All told, the requested one-on-one visit with a nutrition specialist is medically indicated 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 MN15-20412
Overturned Childhood immun · Lungs and breathing The parent of a six-month-old female enrollee has requested Synagis respiratory syncytial virus (RSV) vaccine for treatment of the enrollee’s moderate central sleep apnea with mild obstructive sleep apnea. Findings: The physician reviewer found that the…
The parent of a six-month-old female enrollee has requested Synagis respiratory syncytial virus (RSV) vaccine for treatment of the enrollee’s moderate central sleep apnea with mild obstructive sleep apnea. Findings: The physician reviewer found that the American Academy of Pediatrics (AAP) issued new guidelines for the administration of Synagis for RSV prophylaxis based on review of current peer-reviewed medical literature. Based on the guidelines, “infants with neuromuscular disease or congenital anomaly that impairs the ability to clear secretions from the upper airway because of ineffective cough are known to be at risk for a prolonged hospitalization related to lower respiratory tract infection and, therefore, may be considered for prophylaxis during the first year of life.” This patient, with significant hypotonia due to Prader-Willi syndrome and chromosomal deletion, as well as laryngomalacia and central apnea significant enough to require continuous supplemental oxygen therapy, is at risk for severe respiratory disease should she contract RSV infection because of inability to adequately clear secretions. Based on the AAP guidelines and standards of care, the requested Synagis is medically necessary and appropriate for this patient for the duration of the 2014-2015 RSV seasons.
Case MN15-19446
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).