Rash denials in California external review
In the California DMHC record, independent physician reviewers decided 63 published external-review cases involving rashand overturned the plan’s denial in 38.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for rash
| Category | Decisions | Overturned |
|---|---|---|
| Panniculectomy | 12 | 41.7% |
| Emergency Room | 12 | 0% |
| Skin Treatment | 7 | 57.1% |
| Biologics | 4 | 75% |
| Urgent Care | 3 | 33.3% |
| Tx For Allergies | 3 | 33.3% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 40 | 52.5% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 16 | 6.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 7 | 28.6% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy. Findings: The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS), panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. A Panniculectomy is a noncosmetic procedure typically performed to assist in the correction of a functional impairment. The ASPS states that Patients considered for panniculectomy should document the type and duration of symptoms and treatment for panniculitis. Documented recalcitrant panniculitis may be considered as indication for panniculectomy. Photographs should confirm the patient’s medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a panniculectomy.At issue is whether the requested panniculectomy is medically necessary to treat the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible?
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for excision of excess skin and subcutaneous tissue (includes lipectomy) of the bilateral thighs.According to the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. Only in circumstances is the removal of excess skin in the thighs required to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature.
Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for the removal of excessive thigh skin (thighplasty). Findings: The physician reviewer found that removal of excessive thigh skin (thighplasty) is not medically necessary for the treatment of this enrollee.The enrollee was diagnosed with excess skin status post bariatric surgery. The enrollee’s provider noted the enrollee did not have recurrent infections or functional limitations from the redundant soft tissue on the buttock and thighs, or pain that was directly caused from excess skin. The enrollee’s provider noted the patient previously underwent laparoscopic sleeve gastrectomy, with a preoperative weight of 114 kg. The enrollee’s weight was 81.7 kg, with a body mass index of 26.68.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving rash, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY