In California, both the Department of Managed Health Care (DMHC) and the Department of Insurance (CDI) offer an independent medical review (IMR) process that allows patients to appeal health plan or insurer decisions that deny, modify, or delay treatments based on claims of lack of medical necessity or for being investigational/experimental.

Under California law, patients enrolled in fully insured commercial health plans regulated by either the DMHC or CDI can request an IMR for such denials. This process was established to ensure fair decisions around medical necessity and to bolster public trust in the managed care system.

According to the DMHC’s 2020 Annual Report, 68% of IMR requests resulted in patients receiving the requested service or treatment, while CDI reports that 53% of their IMR cases were resolved in favor of the patient.

The IMR process involves independent physicians who review the case and determine whether the denial was justified. If the denial is found to be inappropriate, the insurer must cover the treatment or service.

Patients must first submit a grievance to their plan or insurer before applying for an IMR. If you disagree with the plan’s decision  or if it has been at least  30 days since the complaint was filed, patients may proceed with an IMR through their plan’s regulator (typically, DMHC regulates HMOs and certain PPOs, while CDI oversees other PPOs).

Physicians can actively support patients through the IMR process, either by helping file or by filing on the patient’s behalf. Patients who want their physician or another representative to file an IMR for them or assist in the process need to complete either the DMHC Authorized Assistant Form or the CDI Designation of IMR Agent form, depending on the regulatory body.

IMR requests should be submitted within six months, though extensions may be granted for special circumstances. There is no cost to apply for an IMR.

For more details on how physicians can assist with IMRs, refer to California Medical Association health law library document #7155, “Independent External Medical Review.”