Health Affairs

Health Affairs, 23, no. 6 (2004): 163-169 doi: 10.1377/hlthaff.23.6.163 © 2004 by Project HOPE	New Online   Getting Health Reform Done   After the State of the Union   Incremental Reform   E-Health in Developing World   Most-Read Articles in 2009

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Independent Medical Review Of Health Plan Coverage Denials: Early Trends

Kenneth H. Chuang, Wade M. Aubry and R. Adams Dudley

Concerns among patients and physicians that health plans would deny coverage for medically necessary services has brought about legislation mandating independent medical review (IMR) of denied services. Among 1,400 cases submitted in California, the most common areas for dispute were cancer care, endocrine/metabolic care (especially for obesity), orthopedic care, and neurological disorders. Surgery and pharmacy services constituted 52 percent of cases. In 58 percent of cases, IMR upheld the health plan’s decision, while in 33 percent of cases the health plan’s decision was overturned, which suggests that external IMR provides additional patient protection in California’s health care system.

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