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Appeal outcomes, by condition
When care for these conditions gets denied and patients push back to independent review, here’s how often the insurer’s decision gets thrown out.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATES · METHODOLOGY
Overturn rate by condition
Conditions with at least 12 published decisions.
All other conditions
Every condition below has its own page with the full record — the denial-type split, the trend, and the reviewers’ own reasoning.
Rotator Cuff Tear · 32.9%Non-small Cell Lung Cancer · 71.8%Ligament Problem · 38%Sacroiliac Joint Pain · 41.4%COPD · 28.6%Spinal Stenosis · 30.4%Chest Pain · 23.2%Bone Fracture Break · 29%CAD · 27.5%Alopecia Areata · 88.2%Sciatica · 26.5%Cervical Spondylosis · 24.2%Substance Abuse · 43.9%Fibroids · 28.8%Cutaneous Melanoma · 1.5%Hypercholesterolemia · 26.2%Borderline Personality Disorder · 55.4%Irritable Bowel Syndrome · 29.2%Joint Problem Pain · 50.8%AlcoholAbuse Addiction · 61.5%Methamphetamine Use Disorder · 70.3%Bacterial Infection · 46.9%Autism · 61.9%Overactive Bladder · 46%Systemic Lupus Erythematosus · 50.8%Rash · 38.1%Osteoarthritis Of The Right Knee · 82.3%Spinal Cord Injury · 45.2%Pelvic Pain · 37.1%Abdominal Stomach Pain · 62.9%Hypogonadism · 60.7%Osteoarthritis Of The Hip · 27.9%Treatment-resistant Depression · 66.7%Muscle Spasms · 41.7%Polysubstance Abuse · 35.6%Radiculopathy · 42.4%Gynecomastia · 30.5%Brain Injury Concussion · 45.8%Injury · 33.9%Endometriosis · 46.6%Chronic Hepatitis C · 81%Allergy · 10.3%Bone · 56.9%Ovarian Cancer · 56.1%Type 1 Diabetes Mellitus · 69.6%Food Allergy · 0%Intertrigo · 37.5%Lymph Nodes · 44.6%Panic Disorder · 54.5%Leukemia · 69.1%Pregnancy · 40.7%Parkinson's Disease · 59.3%Developmental Delay · 77.4%Headache · 35.8%Lipedema · 39.6%Peripheral Neuropathy · 34.6%Polysubstance Dependence · 45.1%Down Syndrome · 74.5%Pancreatic Cancer · 64%Epilepsy · 72%Muscular Dystrophy · 52%ADD · 38%Allergic Rhinitis · 36.7%Resp Allergies · 55.1%Lower Back Pain · 14.6%Temporomandibular Joint Disorder · 41.7%Cystic Fibrosis · 79.2%Lung Cancer · 52.1%Self-harm · 58.3%Develop Delay Ortho · 57.4%Global Developmental Delay · 71.7%Congestive Heart Failure · 32.6%ALS · 63%Myofascial Pain Syndrome · 37%Cardiac Valve Dis · 52.2%Throat Neck · 52.2%Sacroiliac Joint Dysfunction · 44.4%Congenital Deformity · 64.4%Eyelid Droop · 37.8%Transgender · 57.8%Glioblastoma · 47.7%Postural Orthostatic Tachycardia Syndrome · 68.2%Excess Skin · 9.1%Breathing Problem · 56.8%Osteoarthritis Of The Left Knee · 83.7%High Risk Suicide · 65.1%Bilateral Knee Osteoarthritis · 76.2%Heart Attack · 40.5%Breast Cancer Risk · 70.7%Articulation Disorder · 58.5%Hip Osteoarthritis · 39%Neuropathic Pain · 78%Tumor · 63.4%Foot Toe Pain · 63.4%Spondylolisthesis · 52.5%Osteopenia · 30%Chronic Back Pain · 30%Arthritis Oth Joint Dis · 80%Bronchiectasis · 61.5%Hepatitis C Virus Infection · 66.7%Thyroid Nodule · 71.8%Paraplegia · 23.1%Sinusitis · 34.2%Hip Pain · 23.7%Vitiligo · 78.9%Chronic Inflammatory Demyelinating Polyneuropathy · 71.1%Diabetes Mellitus · 63.2%Blood · 65.8%Cardiac Problem · 63.2%Cataracts · 35.1%Glioblastoma Multiforme · 70.3%Sleep Apnea · 37.8%Chromosomal Anomaly · 54.1%Hearing Problem Loss · 51.4%Gastroparesis · 50%Rosacea · 38.9%Spinal Muscular Atrophy · 75%Carpal Tunnel Syndrome · 47.2%Myofascial Pain · 27.8%Mood Disorder · 58.3%Cardiomyopathy · 38.9%Skin Lesion · 66.7%Infection · 41.7%Stress Disorder · 47.2%Male Genital Dis · 47.2%Opioid Dependence · 37.1%Menopause · 22.9%Keratoconus · 88.6%Colon Cancer · 20%Hypothyroidism · 37.1%Disc Inflam Pain Oth Dorsalgia · 54.3%Cyst · 54.3%Deformities · 57.1%Speech Problems · 65.7%Lumbar Degenerative Disc Disease · 17.6%Plagiocephaly · 61.8%Multiple Myeloma · 55.9%Depressive Disorder · 47.1%Urinary Incontinence · 41.2%Vaginal Infection · 35.3%Scoliosis · 42.4%Barrett's Esophagus · 21.2%Peyronie's Disease · 60.6%Otitis Media · 33.3%Hepatitis C Virus Genotype 1b · 84.8%Interstitial Cystitis · 30.3%Nasal Air Obstruct · 42.4%Prostate Problem · 45.5%Viral Infection · 39.4%Abdominal Pannus · 53.1%Ehlers-danlos Syndrome · 68.8%Colorectal Cancer · 46.9%Polycystic Ovarian Syndrome · 78.1%Lumbar Disc Herniation · 18.8%Malignant Melanoma · 12.5%Seizure Disorder · 53.1%Menorrhagia · 37.5%Psychosis · 81.3%Complex Regional Pain Synd RSD · 65.6%Ankylosing Spondylitis · 45.2%Substance Abuse Disorder · 32.3%Duchenne Muscular Dystrophy · 61.3%Breast Pain · 19.4%Hepatocellular Carcinoma · 45.2%Lumbar Spondylosis · 32.3%Chron Kidney Failure ESRD · 77.4%Lymphoma · 71%Bronchitis · 41.9%Low Back Pain With Radiculopathy · 60%Iron Deficiency Anemia · 60%Hepatitis B · 86.7%Constipation · 40%Chronic Sinusitis · 43.3%Heterogeneously Dense Breast Tissue · 96.7%Idiopathic Hypersomnia · 60%Uterine · 50%Throat Infection · 33.3%Medial Meniscus Tear · 34.5%Cervicalgia · 37.9%Prostate Adenocarcinoma · 20.7%Capsular Contracture · 34.5%Cirrhosis · 75.9%Narcolepsy · 48.3%Attention Deficit Disorder · 10.3%Childhood Apraxia Of Speech · 65.5%Ductal Carcinoma In Situ · 62.1%Scleroderma · 20.7%Renal · 41.4%Palpitations · 25%Schizoaffective Disorder · 53.6%Hidradenitis Suppurativa · 75%Hiatal Hernia · 35.7%Cervical Degenerative Disc Disease · 32.1%Trigeminal Neuralgia · 55.6%Dysphagia · 37%Basal Cell Carcinoma · 33.3%Deep Vein Thrombosis · 55.6%Speech And Language Delay · 77.8%Bacterial Vaginosis · 25.9%Expressive Language Disorder · 74.1%Lipedema (Lipoedema) · 44.4%Pituitary Condition · 59.3%Hallux Valgus · 61.5%Alcohol Abuse · 38.5%Irritable Bowel Syndrome With Diarrhea · 96.2%Infertility · 50%Chronic Fatigue Syndrome · 11.5%Epilepsy Seizures Migraine SD · 84.6%Mole · 42.3%UTI · 53.8%Short Of Breath · 46.2%Sacroiliitis · 32%Syncope · 64%Chronic Daily Headache · 44%Language Delay · 72%Paroxysmal Atrial Fibrillation · 44%Expressive Speech Delay · 76%Myasthenia Gravis · 72%Receptive Language Delay · 88%Cervical Dystonia · 80%Meniscal Tear · 40%Hyperhidrosis · 56%Foot Drop · 44%Overbite Underbite · 76%Pediatric Ortho · 76%Pulmonary Fibrosis · 44%Temporomandibular Joint Dysfunction · 50%Small Fiber Neuropathy · 66.7%Tinnitus · 20.8%Nasal Obstruction · 58.3%Cocaine Use Disorder · 58.3%Nasal Valve Collapse · 41.7%Pelvic Congestion Syndrome · 83.3%Intellectual Disability · 54.2%Resp Infection · 41.7%Colitis Inflammatory Bowel Disease · 66.7%Acute Kidney Failure · 66.7%Chronic Fatigue Synd · 16.7%Post Surg Complicat · 33.3%Heel Pain · 29.2%Asperger Syndrome · 58.3%Lateral Epicondylitis · 26.1%Urinary Tract Infection · 56.5%Thyroid Nodule With Indeterminate Cytology · 100%End Stage Renal Disease · 65.2%Patent Foramen Ovale · 56.5%Chondromalacia · 47.8%Polysubstance Use Disorder · 82.6%Invasive Ductal Carcinoma · 56.5%Benzodiazepine Use Disorder · 82.6%Congenital Heart Dft · 69.6%Anemia · 36.4%Hepatitis C Genotype 1 · 72.7%Asperger's Syndrome · 50%Cervical Stenosis · 18.2%Polycystic Ovary Syndrome · 72.7%Chronic Pelvic Pain · 36.4%Metastatic Colorectal Cancer · 59.1%Migraine Headaches · 31.8%Facet Arthropathy · 50%Mixed Receptive-expressive Language Disorder · 54.5%Metastatic Melanoma · 31.8%Recurrent Pregnancy Loss · 18.2%Lumbar Stenosis · 18.2%Acne · 31.8%Helicobacter Pylori Infection · 22.7%Dizziness Vertigo · 50%Blood Clot · 54.5%GI Bleeding · 50%Interstit Cystitis · 27.3%RSV · 59.1%Alzheimer's Disease · 47.6%Thyroid Eye Disease · 71.4%Renal Cell Carcinoma · 33.3%Dementia · 42.9%Breast Asymmetry · 52.4%Adult Growth Hormone Deficiency · 4.8%Thyroid Nodule With Atypia Of Undetermined Significance · 95.2%Keloid · 66.7%Foot Pain · 33.3%Vertebrogenic Low Back Pain · 47.6%Malocclusion · 42.9%Hernia · 47.6%High Risk Pregnancy · 42.9%Female Infertility · 57.1%Chronic Diarrhea · 47.6%Esophagus · 42.9%Miscarriage · 9.5%Chron Kidney Fail · 42.9%Inflammatory Bowel · 33.3%Pneumonia · 30%Degenerative Joint Disease · 40%Hypotonia · 90%Disc Herniation · 20%Uveal Melanoma · 85%Seizures · 60%Dizziness · 40%Non-ischemic Cardiomyopathy · 65%Sarcoma · 70%Respiratory Syncytial Virus Infection · 68.4%Acne Vulgaris · 63.2%Class Iii Obesity · 94.7%Bunion · 42.1%Cerebrovascular Accident · 15.8%Inflammatory Bowel Disease · 57.9%Angina · 31.6%Elevated Prostate Specific Antigen · 0%Dense Breast · 94.7%Chronic Neck Pain · 26.3%Hallux Rigidus · 63.2%Rectal Cancer · 42.1%Dysmenorrhea · 52.6%Ovarian Cyst · 26.3%Apraxia Of Speech · 89.5%Metabolic Disorders · 73.7%Obstructive Airway · 63.2%Tonsillitis · 52.6%Sleep Disorder · 31.6%Mental Hlth Prob · 57.9%Breast Mass · 55.6%Self-injurious Behavior · 72.2%Glaucoma · 55.6%Diastasis Recti · 16.7%Thoracic Outlet Syndrome · 38.9%Colorectal Cancer Screening · 38.9%Pulmonary Hypertension · 33.3%High Cholesterol · 11.1%Pharyngitis · 33.3%Positional Plagiocephaly · 66.7%Labral Tear · 44.4%Trans-femoral Amputation · 50%Central Auditory Processing Disorder · 44.4%Dermatochalasis · 50%Chronic Lymphocytic Leukemia · 66.7%Sensory Processing Disorder · 72.2%Breast Ptosis · 16.7%Eosinophilic Esophagitis · 77.8%Neuropathy · 27.8%Hypertrophic Cardiomyopathy · 66.7%Class 3 Obesity · 94.4%Thoracic Spine Pain · 33.3%Hypertriglyceridemia · 38.9%Brain Tumor · 44.4%Diabetes Mellitus Type 2 · 83.3%Renal Kidney · 55.6%Deviated Septum · 61.1%Septal Deformity · 66.7%Myocardial Infarction · 41.2%Post Laminectomy Syndrome · 29.4%Gout · 29.4%Mast Cell Activation Syndrome · 41.2%Cervical Pain · 41.2%Menopausal Symptoms · 5.9%Hepatitis C Virus Genotype 2b · 82.4%Pes Planus · 58.8%Adhesive Capsulitis · 23.5%Metastatic Colon Cancer · 17.6%Prader-willi Syndrome · 64.7%Fecal Incontinence · 76.5%Failed Back Surgery Syndrome · 64.7%Autistic Disorders · 47.1%Cervical · 47.1%Pancreatitis · 58.8%Pelvic Inflam Dis · 52.9%Heart Disease · 47.1%Aneurysm · 76.5%Metatarsalgia · 75%Intractable Epilepsy · 93.8%Psoriasis Vulgaris · 62.5%Sensorineural Hearing Loss · 50%Psychotic Disorder · 87.5%Cellulitis · 43.8%Venous Insufficiency · 50%Cholangiocarcinoma · 56.3%Bulimia · 37.5%Self-harm Behavior · 81.3%Piriformis Syndrome · 37.5%Bipolar Ii Disorder · 37.5%Hypoglycemia · 93.8%Severe Persistent Asthma · 87.5%Dilated Cardiomyopathy · 25%Stuttering · 56.3%Alopecia Universalis · 93.8%Gastritis · 37.5%Upper Respiratory Infection · 31.3%Right Knee Osteoarthritis · 75%Treatment-resistant Major Depressive Disorder · 93.8%Rectal Bleeding · 43.8%Intracranial Hemorrhage · 31.3%Ankle Fracture · 50%Hip Fracture · 31.3%Head Neck Throat · 37.5%Borderline Personality Dis · 62.5%Skin Ulcer · 25%Ankle Osteoarthritis · 40%Atherosclerotic Cardiovascular Disease · 46.7%Cannabis Dependence · 53.3%Ischemic Stroke · 46.7%Suicidality · 93.3%Endometrial Cancer · 46.7%Common Variable Immunodeficiency · 53.3%Rupture Of Membranes · 0%Hepatitis C Virus Infection, Genotype 1a · 86.7%Ankle Pain · 40%Hepatitis C Genotype 1a · 73.3%Arrhythmia · 26.7%Lynch Syndrome · 66.7%Leg Pain · 20%Post-concussion Syndrome · 13.3%Lumbar Pain · 33.3%Iga Nephropathy · 66.7%Hepatitis C Virus Genotype 3a · 86.7%Dry Eye Disease · 73.3%Diabetic Foot Ulcer · 53.3%Type Ii Diabetes Mellitus · 40%Anoxic Brain Injury · 40%Hallux Limitus · 33.3%Small Fiber Polyneuropathy · 80%Pelvic Floor Dysfunction · 60%Quadriplegia · 40%Femoroacetabular Impingement · 46.7%Anal Rectal · 46.7%Male Genital Disorder · 33.3%Malignant Tumor · 53.3%Patellofemoral Arthritis · 57.1%Delayed Speech · 64.3%Conduct Disorder · 57.1%Adenocarcinoma Of The Prostate · 21.4%Insulin Resistance · 100%Plantar Hyperhidrosis · 78.6%Receptive And Expressive Language Delay · 78.6%Cervical Myelopathy · 35.7%Premature Ventricular Contractions · 50%Torticollis · 85.7%Metastatic Non-small Cell Lung Cancer · 64.3%Eczema · 42.9%Chronic Hepatitis B · 78.6%Actinic Keratosis · 50%Systemic Sclerosis · 35.7%Expressive Language Impairment · 100%Reactive Attachment Disorder · 42.9%Left Knee Pain · 7.1%Diabetic Neuropathy · 50%Foraminal Stenosis · 21.4%Nephrotic Syndrome · 85.7%Cervical Disc Disease · 28.6%Osteoarthritis Of Both Knees · 92.9%Osteomyelitis · 50%Lumbar Disc Degeneration · 35.7%Discogenic Low Back Pain · 28.6%Invasive Ductal Carcinoma Of The Breast · 64.3%Rhinitis · 42.9%Pes Planus Flat Feet · 64.3%Strabismus · 28.6%Impacted Teeth · 57.1%CHF · 14.3%Sev Emot Disturb · 42.9%Perv Devlop Disorder · 85.7%Failure To Thrive · 76.9%Specific Antibody Deficiency · 38.5%Guillain-barré Syndrome · 15.4%Cervical Disc Herniation · 15.4%Osteoarthritis Of The Ankle · 61.5%Polyneuropathy · 23.1%Radicular Pain · 38.5%Deviated Nasal Septum · 84.6%Focal Segmental Glomerulosclerosis · 84.6%Lumbar Spondylolisthesis · 7.7%Nausea · 53.8%Rett Syndrome · 76.9%Convergence Insufficiency · 46.2%Binge Eating Disorder · 61.5%Excess Abdominal Skin · 30.8%Abnormal Uterine Bleeding · 30.8%Amphetamine Use Disorder · 84.6%Leg Length Discrepancy · 23.1%Diarrhea · 38.5%Sarcoidosis · 61.5%Hearing Loss · 38.5%Food Allergies · 15.4%Excessive Daytime Sleepiness · 38.5%Anterior Cruciate Ligament Reconstruction · 38.5%Allergies · 46.2%Brachycephaly · 84.6%Pulmonary Nodule · 23.1%Ischemic Cardiomyopathy · 61.5%Immunoglobulin A Nephropathy · 61.5%Pervasive Developmental Disorder · 61.5%Non-suicidal Self-injury · 69.2%Chronic Headache · 30.8%Transient Ischemic Attack · 53.8%Pressure Ulcer · 38.5%Triple Negative Breast Cancer · 76.9%Ptosis · 38.5%Lupus Nephritis · 92.3%Ventral Hernia · 46.2%Lumbar Facet Arthropathy · 46.2%Dry Eyes · 61.5%Kidney Stones · 53.8%Abscess · 15.4%Temporomandibular Disorder · 75%Thoracic Pain · 25%Single-sided Deafness · 50%Fatigue · 41.7%Acute Myeloid Leukemia · 83.3%Anaphylaxis · 83.3%Major Depressive Disorder With Psychotic Features · 58.3%Meningioma · 16.7%Hepatitis C Virus Genotype 3 · 100%Cannabis Abuse · 50%Cocaine Dependence · 25%Overweight · 66.7%Dental Caries · 75%Hypogammaglobulinemia · 41.7%Lipoma · 50%Meniscus Tear · 25%Left Ventricular Dysfunction · 58.3%Sepsis · 50%Breast Lesion · 75%Lipodystrophy · 58.3%Auditory Processing Disorder · 33.3%Celiac Disease · 58.3%Hemorrhoids · 8.3%Right Shoulder Pain · 33.3%Pudendal Neuralgia · 33.3%Chronic Idiopathic Constipation · 66.7%Heterogeneously Dense Breasts · 100%Pulmonary Embolism · 41.7%Cervical Spinal Cord Injury · 58.3%Microcephaly · 83.3%Testosterone Deficiency · 16.7%Chronic Hepatitis C Genotype 1a · 91.7%Septal Deviation · 33.3%Mixed Hyperlipidemia · 25%Lipid Storage Dis · 16.7%