Prescription Drugs denials in California external review
In the California DMHC record, independent physician reviewers decided 11,948 published external-review cases involving prescription drugs and overturned the plan’s denial in 60.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By denial reason
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 10,653 | 61.8% |
| experimental / investigational | 1,295 | 48.3% |
Within this category
| Subcategory | Decisions | Overturned |
|---|---|---|
| Other | 1,825 | 47.6% |
| Weight Control | 1,582 | 86.3% |
| Anti-virals | 1,351 | 81.4% |
| Hormones | 971 | 43% |
| Biologics | 527 | 78.2% |
| Skin Treatment | 519 | 69% |
| Botox Injection | 518 | 57.9% |
| Pain Medication | 413 | 32.4% |
| Arthritis Rx | 400 | 56% |
| IVIG Therapy | 385 | 49.1% |
| Non-FDA Approved Use | 384 | 43.5% |
| Diabetic Medication | 288 | 74.7% |
| Anti-inflammatories | 266 | 52.6% |
| Digestion/GI Rx | 229 | 79.5% |
| Antibiotics | 202 | 41.6% |
| Formulary v Non Form | 197 | 39.6% |
| Cardiac Rx | 180 | 38.9% |
| Analgesics | 179 | 20.1% |
| Migraine Rx | 172 | 83.1% |
| Neuromuscular RX | 111 | 81.1% |
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. | 10,653 | 61.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 1,295 | 48.3% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that the patient has requested authorization and coverage for Zepbound. Obesity is a multi-causal chronic disease recognized across a patient’s lifespan resulting from long-term positive energy balance and the development of excess adiposity that, over time, leads to structural abnormalities, physiological derangements, and functional impairments. The disease of obesity increases the risk of developing other chronic diseases and is associated with premature mortality. As with other chronic diseases, obesity is distinguished by multiple phenotypes, clinical presentations, and treatment responses. The U.S.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zepbound auto-injector pen. Obesity is a multi-causal chronic disease recognized across a patient’s lifespan resulting from long-term positive energy balance and the development of excess adiposity that, over time, leads to structural abnormalities, physiological derangements, and functional impairments. The disease of obesity increases the risk of developing other chronic diseases and is associated with premature mortality. As with other chronic diseases, obesity is distinguished by multiple phenotypes, clinical presentations, and treatment responses. The U.S.
Where the denial was upheld
Physician 1The patient is a 69-year-old woman who has followed a typical course for Takayasu’s arteritis and has stenosis of the left subclavian artery, carotid arteries, right vertebral artery, left ulnar artery, and branches of the aorta supplying the kidneys. She has had numerous bypass surgeries to maintain blood flow to her upper extremities and stenting of her renal arteries. In September 2003, studies revealed 70% stenosis of her celiac axis and superior mesenteric artery. The patient’s disease continues to be very aggressive despite prednisone treatment and Plaquenil. The patient’s provider has recommended Enbrel. The Health Plan has denied authorization for Enbrel on the basis that it is considered investigational for treatment of Takayasu’s arteritis.The pathogenesis of Takayasu’s arteritis and temporal arteritis are very similar.
Physician 1The patient is a 34-year-old female first diagnosed with Lyme disease in 2001. She subsequently received multiple courses of antibiotic with minimal long-term results. She had one six-month course of antibiotic with minimal change in her condition. She reports experiencing fatigue, paresthesia, arthralgias, fever, photophobia and headaches. These symptoms have persisted for several years. The patient feels the symptoms are increasing in severity. Physical exam findings include peripheral neuropathy with no effusions or erosion of large joints. Laboratory data include a positive IgG Western blot, normal brain MRI, and abnormal nerve conduction studies. No CSF analysis has been provided. A request has been made for continued intravenous antibiotic therapy.
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 category of care 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 prescription drugs, 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