Legally reviewed By Scott Glovsky in Insurance and Healthcare Denials
If your health plan has denied treatment your doctor believes you need, requesting an Independent Medical Review (IMR) can feel like one more hurdle in an already difficult process. Before pursuing one, you may reasonably want to know whether other Californians have successfully challenged similar health insurance denials.
The California Department of Managed Health Care (DMHC) publishes data that provides useful context. According to the DMHC, approximately 73% of IMR cases resulted in the health plan’s denial being reversed by the plan or overturned by the independent review process, with the enrollee receiving authorization for the requested service or treatment. The figure is based on the DMHC’s 2024 Annual Report (the latest DMHC Annual Report published).
That does not mean your individual chance of success is 73%. The IMR overturn rate in California depends on what is being measured, and every case turns on its own medical facts. But the data does show that eligible patients who challenge denials through the IMR process sometimes receive a different outcome.
If you have burning questions, don’t navigate this alone. Call us at 626-243-5598 or contact us online to schedule your free consultation for some clarity.
💡 Key Takeaways
- Roughly 73% of 2024 California IMR cases resulted in authorization:
According to the DMHC’s 2024 Annual Report, most enrollees who pursued an Independent Medical Review received authorization for the requested treatment, whether through a plan reversal or an IMR overturn. - “Reversed” and “overturned” are not the same outcome:
A health plan reversal happens when the insurer changes its own decision. An IMR overturn happens when independent reviewers disagree with the plan. The 73% figure includes both. - Outcomes vary significantly by insurer:
2024 authorization rates ranged from 47.5% for Kaiser Permanente to 87.1% for UnitedHealthcare Benefits Plan of California, showing that statewide averages can mask real differences between health plans. - Statewide statistics can’t predict your individual outcome:
An IMR evaluates the specific medical facts of your case. Historical data shows that outcomes can change through the process, but it can’t tell you how your case will be decided. - Your doctor’s documentation is central to a successful IMR:
A strong IMR request directly addresses the insurer’s stated reason for denial, supported by your physician’s explanation of medical necessity, treatment history, and relevant clinical guidelines.
What Does the Latest DMHC IMR Data Show?
The DMHC reports that approximately 73% of IMR cases resulted in the enrollee receiving authorization for the requested service or treatment in 2024. There is an important distinction within that number. The DMHC describes these cases as denials that were either reversed by the health plan or overturned by the Independent Medical Review Organization.
Those are not the same outcome.
A health plan reversal occurs when the plan changes its own decision during the process. An IMR overturn occurs when the independent medical reviewers disagree with the health plan’s decision. Both may ultimately result in the patient receiving authorization for care, but it would be misleading to describe the entire 73% figure as the IMR overturn rate.
This distinction is important if you are researching health insurance denial overturn statistics. Statistics can look more definitive than they are if the outcomes being measured aren’t clearly explained.
Looking at specific California health insurance companies and denials based on medical necessity, 76.4% of Anthem Blue Cross members, 81.5% of Blue Shield of California members, 80.2% of Health Net of California members, 71.4% of Cigna members, 87.1% of UnitedHealthcare Benefits Plan of California members, and 47.5% of Kaiser Permanente members received the medical care they sought after submitting IMRs to the DMHC in 2024.
What Types of Denials Can Qualify for an IMR?
The DMHC does not send every health insurance dispute to independent medical reviewers. An IMR is designed for certain disputes involving medical decisions.
According to the DMHC, a request may qualify when a health plan:
- Denies, modifies, or delays treatment because it determines the care is not medically necessary;
- Refuses to cover treatment because it considers the treatment experimental or investigational; or
- Refuses to pay for emergency or urgent medical services the patient has already received.
This nuance matters when evaluating medical necessity IMR outcomes or other IMR statistics. A dispute over whether your doctor’s recommended treatment is medically necessary raises different questions from a disagreement about whether a particular benefit exists under your insurance contract.
Can IMR Data Tell You Your Chances of Overturning a Denial?
No. Statewide statistics describe what happened in previous cases. They cannot predict the result of an individual IMR.
An independent reviewer evaluates the medical circumstances presented in your case. Your diagnosis, medical history, previous treatments, response to those treatments, treating physician’s recommendation, and the reason your health plan gave for denying care may all be relevant.
This is why the question of how often health insurance denials are overturned only tells part of the story. Historical data can tell you that health plan decisions have changed during the IMR process. It cannot tell you whether the medical evidence in your case will persuade an independent reviewer to reach a different conclusion.
That distinction matters when deciding whether and how to pursue an IMR. The overall statistics should not replace a careful review of your denial and the evidence supporting the treatment your doctor recommends.
What Can You Learn from Past California IMR Decisions?
The statewide percentage is not the only information available to California patients. The DMHC maintains a searchable database containing IMR decisions dating back to the beginning of the program on January 1, 2001. Reviewing past decisions may provide context about how independent reviewers have evaluated disputes involving particular treatments, diagnoses, or medical issues.
You still need to read past decisions carefully. A favorable decision involving the same treatment you were denied does not establish that your health plan must approve your treatment. Medical circumstances are unique to patients, and independent reviewers evaluate the evidence in each case.
However, past decisions can help illustrate the types of information reviewers consider and how medical evidence has been evaluated in previous disputes. They can also provide more context than relying on a statewide percentage alone.
Why Does Your Doctor’s Documentation Matter?
An IMR is ultimately a review of a medical dispute. That makes the information your treating physician provides particularly important.
If your health plan denied treatment as medically unnecessary, for example, simply submitting more medical records may not address the reason for the denial. Your physician may be able to explain why the recommended treatment is appropriate for your specific condition, why alternatives are not appropriate or have already failed, and how the insurer’s medical criteria apply to your circumstances.
The denial letter can provide a useful starting point. If it identifies a medical policy or clinical guideline, ask your physician to review the insurer’s reasoning. The goal is to ensure the independent reviewers have the medical information needed to evaluate your circumstances, rather than simply reviewing the same materials that led to the original denial.
Depending on the case, relevant medical literature or current treatment guidelines such as standards of care may also help explain why the requested care is appropriate.
What Should You Take Away from the California IMR Statistics?
The DMHC IMR data offers an important insight: Health plan denials change during the IMR process. If you are deciding whether to request an IMR, focus first on why your health plan denied the treatment. Review the medical criteria it relied on. Talk with your treating physician about the denial and the evidence supporting the requested care. You can also review the DMHC’s database of previous IMR decisions for additional context.
Those steps may tell you considerably more about your situation than an overall percentage can.
Before You Submit an IMR, Know What Is at Stake
An Independent Medical Review can provide an important opportunity to challenge a health insurance denial, but the decision you receive will likely also affect what happens next. If you are unsure whether an IMR is the right step, it may be worth having your denial, medical evidence, and health plan reviewed before you file.
For nearly three decades, the Law Offices of Scott Glovsky has successfully helped Californians challenge health insurance denials and fight for access to medically necessary care. We can review why your treatment was denied, the options available under your health plan, and the issues you should consider before moving forward with an IMR.
If your health insurer has denied care your doctor recommends, contact us online or call 626-243-5598 to discuss your situation and the next steps that may be available.
Legal and Data References Used to Inform This Page
To ensure the accuracy and clarity of this page, we referenced official California resources during the content development process: