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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.

Condition	Decisions	Overturned on review
Obesity	1,389	85.3%
Osteoarthritis	1,019	76.6%
Autism	1,009	64.8%
Hepatitis C	928	82.9%
Breast Cancer	755	68.5%
Prostate Cancer	456	32.9%
Low Back Pain	412	25.7%
Major Depressive Disorder	350	55.4%
Multiple Sclerosis	316	60.1%
Psoriasis	301	73.1%
Back Pain	294	23.5%
Crohn's Disease	287	65.2%
Autism Disorder	278	65.1%
Depression	256	50.8%
Pregnancy	252	55.6%
Gender Dysphoria	248	83.5%
Migraine	242	66.5%
Obstructive Sleep Apnea	213	53.1%
Chronic Low Back Pain	212	42%
Eating Disorder	202	53.5%
Gastroesophageal Reflux Disease	195	26.2%
Idiopathic Short Stature	184	41.8%
Hepatitis C Virus	179	67%
Osteoporosis	178	56.2%
Asthma	171	49.1%
Melanoma	166	13.9%
Atopic Dermatitis	163	85.3%
Bipolar Disorder	161	47.8%
Diabetes	160	60.6%
Medical Condition	156	78.8%
Speech Delay	150	86%
Neck Pain	148	29.7%
Chronic Pain	146	26%
Degenerative Disc Disease	141	14.9%
Type 2 Diabetes	137	75.9%
Ulcerative Colitis	137	66.4%
Rheumatoid Arthritis	137	48.9%
Hepatitis_c	134	88.1%
ADHD	130	55.4%
Hyperlipidemia	124	31.5%
Varicose Veins	117	35.9%
Migraine Headaches	116	48.3%
Dense Breasts	108	95.4%
Short Stature	106	35.8%
Major Depression	106	45.3%
Knee Osteoarthritis	105	73.3%
Coronary Artery Disease	105	27.6%
OSA	103	73.8%
Behavioral Health	103	43.7%
Fibromyalgia	102	33.3%
Stroke	100	34%
Pain	96	30.2%
Migraines	95	67.4%
Diabetes Mellitus	93	63.4%
Chronic Rhinosinusitis	90	77.8%
Cerebral Palsy	90	51.1%
Knee Pain	90	35.6%
Erectile Dysfunction	86	61.6%
Abdominal Pain	85	40%
Lymphedema	84	66.7%
Behavioral Health Condition	83	43.4%
Chronic Migraine	82	73.2%
Type 1 Diabetes	81	80.2%
Type 2 Diabetes Mellitus	79	78.5%
Hypertension	76	35.5%
Occipital Neuralgia	75	64%
Macromastia	75	60%
Plantar Fasciitis	73	37%
Thyroid Nodule	72	87.5%
Anorexia Nervosa	71	56.3%
Colon Cancer	68	27.9%
Lung Cancer	66	50%
Lyme Disease	65	3.1%
Chronic Migraines	64	82.8%
Onychomycosis	64	46.9%
Psoriatic Arthritis	63	46%
Traumatic Brain Injury	62	40.3%
Growth Hormone Deficiency	62	50%
Colorectal Cancer	62	40.3%
Chronic Back Pain	62	27.4%
Ovarian Cancer	62	46.8%
Atrial Fibrillation	61	63.9%
Lower Back Pain	58	27.6%
Alopecia Areata	57	86%
Uterine Fibroids	57	29.8%
Spinal Cord Injury	56	46.4%
GERD	56	44.6%
Sleep Apnea	55	45.5%
Alcohol Dependence	55	40%
Hypogonadism	54	53.7%
Glioblastoma	54	51.9%
Digestive System	53	28.3%
Gynecomastia	53	32.1%
Insomnia	52	38.5%
Osteopenia	51	35.3%
Bulimia Nervosa	51	52.9%
Morbid_obesity	51	47.1%
Osteoarthritis Of The Knee	50	56%
Epilepsy	50	84%
Lipedema	49	42.9%
Lumbar Radiculopathy	49	40.8%
Overactive Bladder	48	47.9%
Spinal Stenosis	48	31.3%
Headache	48	37.5%
Endometriosis	47	46.8%
Shoulder Pain	47	31.9%
Bilateral Knee Osteoarthritis	47	66%
Chronic Sinusitis	47	38.3%
Lumbar Spinal Stenosis	46	28.3%
Metastatic Breast Cancer	45	46.7%
Pancreatic Cancer	45	51.1%
Non-small Cell Lung Cancer	44	68.2%
Neuromusc Dis	44	29.5%
Alcohol Use Disorder	44	50%
Chest Pain	43	18.6%
Prediabetes	42	59.5%
Headaches	42	42.9%
Irritable Bowel Syndrome	42	42.9%
Hypothyroidism	42	45.2%
Cystic Fibrosis	42	78.6%
Behavioral Health Conditions	42	19%
Behavioral Health Problems	42	40.5%
Neuropathic Pain	41	80.5%
Narcolepsy	41	39%
Bronchiectasis	41	61%
Multiple Myeloma	41	56.1%
Mental Health	40	72.5%
Hypercholesterolemia	40	27.5%
Benign Prostatic Hyperplasia	40	40%
Behavioral Health Issues	40	52.5%
Blood Related Disorder	39	46.2%
Cervical Radiculopathy	38	36.8%
Right Knee Osteoarthritis	38	52.6%
Arthritis	38	36.8%
Colonoscopy	38	7.9%
Vitiligo	37	78.4%
Rosacea	37	37.8%
Hyperhidrosis	36	61.1%
Keratoconus	36	88.9%
Parkinson's Disease	36	58.3%
Sibo	35	80%
Abdominal Pannus	35	25.7%
Down Syndrome	34	82.4%
Pelvic Pain	34	32.4%
Paraplegia	34	26.5%
Constipation	34	47.1%
Hepatitis_b	33	93.9%
Crps	32	46.9%
Glioblastoma Multiforme	32	65.6%
Anxiety	32	25%
Food Allergy	32	0%
Foot Pain	32	46.9%
Skin_disorders	31	45.2%
Capsular Contracture	31	25.8%
Substance Abuse	31	22.6%
Gastroparesis	30	46.7%
Neck And Back Pain	30	20%
Kidney Disorder	30	50%
Cardiomyopathy	30	33.3%
Morbid-obesity	30	33.3%
Language Delay	30	96.7%
Malignant Melanoma	29	17.2%
Autistic Disorder	29	86.2%
Inflammatory Bowel Disease	28	53.6%
Left Knee Pain	28	28.6%
Coronary Disease	28	28.6%
Sciatica	28	32.1%
Rsv	28	75%
IBS	28	39.3%
Hidradenitis Suppurativa	27	74.1%
Sacroiliac Joint Pain	27	33.3%
Null	27	14.8%
Sle	27	51.9%
ALS	27	74.1%
Urinary Incontinence	27	18.5%
Acne	27	40.7%
Ankylosing Spondylitis	27	40.7%
Articulation Disorder	27	51.9%
Hepatitis_c_virus	27	85.2%
Growth_hormone_deficiency	26	65.4%
Neuropathy	26	50%
Myasthenia Gravis	26	69.2%
Cutaneous Melanoma	26	3.8%
Right Knee Pain	26	30.8%
Schizoaffective Disorder	26	46.2%
Anxiety Disorder	26	42.3%
Small Fiber Neuropathy	25	56%
Chronic Pelvic Pain	25	52%
Neuromusc_dis	25	56%
Basal Cell Carcinoma	25	36%
Chronic Obstructive Pulmonary Disease	25	20%
Hearing Loss	25	36%
Food Allergies	25	4%
Polysubstance Abuse	25	32%
Cidp	24	70.8%
Peyronie's Disease	24	62.5%
Rectal Cancer	24	41.7%
Spinal Muscular Atrophy	24	75%
Interstitial Cystitis	24	25%
Ibs-d	23	100%
Sinusitis	23	34.8%
Allergic Rhinitis	22	50%
Complex Regional Pain Syndrome	22	36.4%
Substance Use Disorder	22	36.4%
Congestive Heart Failure	22	36.4%
OCD	22	77.3%
Plagiocephaly	22	59.1%
Palpitations	22	18.2%
Chronic Pain Syndrome	22	18.2%
Type I Diabetes	22	54.5%
Overweight	21	66.7%
Chronic Neck Pain	21	28.6%
Left Knee Osteoarthritis	21	57.1%
Dementia	21	33.3%
Hip Pain	21	28.6%
Cervical Dystonia	21	76.2%
Small Intestinal Bacterial Overgrowth	21	76.2%
Cervical Spondylosis	21	23.8%
Dyslipidemia	21	0%
Eczema	21	57.1%
Developmental Delay	21	71.4%
Polysubstance Dependence	21	38.1%
Expressive Language Delay	21	95.2%
Atherosclerotic Cardiovascular Disease	20	25%
Generalized Anxiety Disorder	20	55%
Type 1 Diabetes Mellitus	20	70%
Pots	20	55%
Trigeminal Neuralgia	20	60%
Reflux Disease	20	0%
Nephrotic Syndrome	20	95%
Sacroiliac Joint Dysfunction	20	35%
Glaucoma	20	45%
Quadriplegia	20	35%
Borderline Personality Disorder	20	60%
Degenerative Joint Disease	20	35%
Tinnitus	20	20%
Menopausal Symptoms	20	20%
Idiopathic Hypersomnia	19	52.6%
Duchenne Muscular Dystrophy	19	52.6%
Seizures	19	52.6%
Dizziness	19	36.8%
Gastric Cancer	19	47.4%
Myofascial Pain Syndrome	19	36.8%
Scoliosis	19	26.3%
Prostate Adenocarcinoma	19	21.1%
Thyroid Eye Disease	19	73.7%
Schizophrenia	19	52.6%
Chronic Fatigue Syndrome	19	15.8%
Mental Illness	19	73.7%
Metastatic Melanoma	19	31.6%
Bacterial Vaginosis	18	27.8%
Osteoarthritis Of The Right Knee	18	77.8%
Rhinosinusitis	18	83.3%
Pelvic Congestion Syndrome	18	83.3%
Right Knee	18	22.2%
Rotator Cuff Tear	18	38.9%
Cholangiocarcinoma	18	44.4%
Infertility	18	38.9%
Osteoarthritis Of The Left Knee	18	88.9%
Knee	18	27.8%
Myofascial Pain	18	16.7%
Nasal Obstruction	18	72.2%
Adenocarcinoma Of The Prostate	18	16.7%
Depressive Disorder	18	33.3%
Breast	18	77.8%
Excess Skin	18	16.7%
Sore Throat	18	16.7%
Hepatitis B	17	82.4%
Chronic Kidney Disease	17	47.1%
Urinary Tract Infection	17	58.8%
Hypoglycemia	17	94.1%
Atriial Fibrillation	17	58.8%
Global Developmental Delay	17	58.8%
Ankle Pain	17	29.4%
Mood Disorder	17	41.2%
Lipodystrophy	17	41.2%
Diabetes_mellitus	16	50%
Pediatric Growth Hormone Deficiency	16	50%
Breast Hypertrophy	16	68.8%
Hip Osteoarthritis	16	18.8%
Heart Failure	16	56.3%
Panic Disorder	16	62.5%
Coronary Risk	16	0%
Dense Breast Tissue	16	87.5%
Cervicalgia	16	25%
Hypertrophic Cardiomyopathy	16	62.5%
Left Knee	16	37.5%
Hepatocellular Carcinoma	16	43.8%
Uveal Melanoma	16	81.3%
HIV	16	56.3%
Sma	16	75%
Adenocarcinoma	16	31.3%
Chronic Headaches	16	43.8%
Depression Anxiety	16	37.5%
Seizure Disorder	16	75%
Anemia	16	56.3%
Chemical Dependency	16	25%
Asperger's Syndrome	16	50%
Class Iii Obesity	15	100%
Diabetes_mellitus_type_2	15	93.3%
Musculoskeletal Pain	15	13.3%
Trauma	15	33.3%
Alopecia	15	73.3%
Iron Deficiency Anemia	15	60%
Sacroiliitis	15	33.3%
Systemic Lupus Erythematosus	15	46.7%
Eosinophilic Esophagitis	15	86.7%
Ehlers-danlos Syndrome	15	33.3%
Idiopathic-short-stature	15	40%
Myocardial Infarction	15	20%
Sarcoidosis	15	66.7%
Alopecia Universalis	15	93.3%
Lyme_disease	15	6.7%
Psychosis	15	60%
Opioid Dependence	15	40%
Pcos	14	71.4%
Anaphylaxis	14	78.6%
Post-traumatic Stress Disorder	14	57.1%
Meningioma	14	28.6%
Cellulitis	14	42.9%
Diabetes Mellitus Type 2	14	64.3%
Type I Diabetes Mellitus	14	42.9%
Brain Tumor	14	35.7%
Nausea	14	50%
Skin Disorder	14	35.7%
Barretts Esophagus	14	7.1%
Gout	14	42.9%
Convergence Insufficiency	14	50%
Peripheral Neuropathy	14	42.9%
COPD	14	35.7%
Menopause	14	0%
Ductal Carcinoma In Situ	14	57.1%
Gender Identity Disorder	14	57.1%
Hemorrhoids	14	21.4%
Heart Disease	13	46.2%
Growth Failure	13	46.2%
Chronic Abdominal Pain	13	30.8%
Polyneuropathy	13	46.2%
Leiomyosarcoma	13	69.2%
Bph	13	46.2%
Breast Pain	13	30.8%
Left Ventricular Dysfunction	13	30.8%
Cervical Stenosis	13	7.7%
Spondylolisthesis	13	46.2%
Pandas	13	23.1%
Dilated Cardiomyopathy	13	23.1%
Nsclc	13	84.6%
PTSD	13	61.5%
Osteoarthritis Knee	13	61.5%
Lateral Epicondylitis	13	23.1%
Heel Pain	13	30.8%
Scleroderma	13	23.1%
Renal Cell Carcinoma	13	53.8%
Celiac Disease	13	46.2%
Attention Deficit Hyperactivity Disorder	13	23.1%
Endometrial Cancer	13	46.2%
Squamous Cell Carcinoma	13	53.8%
Ear Pain	13	23.1%
Lumbar Degenerative Disc Disease	12	25%
Polycystic Ovarian Syndrome	12	41.7%
Cerebrovascular Accident	12	25%
Atherosclerotic Heart Disease	12	58.3%
Ptosis	12	33.3%
Bladder Cancer	12	50%
Lumbar Stenosis	12	25%
Pneumonia	12	58.3%
Right Shoulder Pain	12	41.7%
Bilateral Knee Pain	12	16.7%
Hypogammaglobulinemia	12	33.3%
Obsessive-compulsive Disorder	12	75%
Acl Reconstruction	12	58.3%
Thyroid Cancer	12	58.3%
Maxillofacial Skeletal Deformity	12	100%
Metastatic Colon Cancer	12	25%
TMJ Disorder	12	58.3%
Diarrhea	12	33.3%
Infectious_disease	12	25%
Diabetic Neuropathy	12	25%
Osteoarthritis Of The Knees	12	75%
Cataract	12	33.3%
Pes Planus	12	41.7%
Chronic Idiopathic Constipation	12	66.7%
Migraine Headache	12	50%
Rash	12	25%
Piriformis Syndrome	12	41.7%
Delayed Speech	12	75%

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