Independent Medical Review (IMR): An Important Tool for Challenging Health Insurance Denials in California
When a health insurance company denies coverage for a treatment, procedure, medication, or medical service by claiming it is “not medically necessary,” “experimental,” or “investigational,” policyholders often feel like they have nowhere to turn. Fortunately, California law provides an important consumer protection mechanism called the Independent Medical Review (IMR) process. An IMR allows patients to have medical necessity disputes reviewed by independent medical professionals rather than by the insurance company that denied the claim. The process has become a powerful tool for overturning wrongful denials and ensuring that patients receive medically necessary care.
At Gianelli & Morris, we regularly help policyholders whose health insurance claims have been denied in bad faith. While an Independent Medical Review can be an effective remedy in many cases, it is not appropriate for every dispute, and an insurer’s conduct during the review process may itself constitute insurance bad faith. In addition, the IMR does not always end in a correct decision, and legal consultation is important to making sure your position is adequately represented in this vital process.
What Is an Independent Medical Review?
California’s Independent Medical Review program was established in 2001 to give policyholders an impartial method of challenging certain health insurance denials. The process is administered by state regulators rather than by the insurance company itself. Depending on the type of policy, an IMR may be handled by either the California Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI). The appropriate agency depends on which regulator oversees the health plan in question.
During an IMR, independent physicians and medical experts review the insurance company’s decision and determine whether the requested treatment or service should be covered. The reviewers are not employees of the insurer and must evaluate the dispute according to accepted standards of medical practice.
The reviewers consider numerous factors, including:
- The patient’s medical records and circumstances;
- Recommendations from treating physicians;
- Peer-reviewed medical literature;
- Accepted standards of care;
- Expert medical opinions; and
- Scientific evidence concerning the requested treatment.
If the independent reviewers determine that the insurer improperly denied coverage, the health plan must generally authorize and pay for the treatment.
California regulators have emphasized that IMRs are an important consumer protection mechanism because independent reviewers frequently disagree with insurers’ original decisions. According to the DMHC’s 2024 annual data, health plans regulated by the department were involved in 3,477 IMRs, and approximately 53% of standard IMR denials were overturned, requiring the plans to provide the requested services.
When Can a Policyholder Request an IMR?
Not every insurance dispute qualifies for Independent Medical Review. Generally, IMRs are available when a health plan has denied, delayed, or modified care based on medical judgment rather than policy interpretation.
Common situations include:
- Denials based on alleged lack of medical necessity;
- Claims that a treatment is experimental or investigational;
- Denials involving urgent or emergency services; and
- Delays in approving medically necessary care.
Most policyholders must first complete the insurer’s internal appeals process before requesting an IMR. However, California law allows expedited review in certain circumstances involving serious or imminent threats to a patient’s health. For example, if delaying treatment could result in serious pain, loss of life, loss of bodily function, or rapid deterioration of a medical condition, regulators may waive the requirement that internal appeals be exhausted before the IMR proceeds. In expedited cases, decisions may be issued within just a few days rather than the standard review timeline.
What Types of Disputes Are Not Appropriate for IMRs?
Independent Medical Reviews focus on medical decision-making, not legal disputes about policy interpretation.
An IMR generally cannot resolve issues involving:
- Questions about whether a policy provides coverage in the first place;
- Allegations of insurance bad faith;
- Disputes regarding underwriting decisions;
- Rescission of coverage;
- Life insurance claim denials; or
- Other contractual issues unrelated to medical necessity.
For example, if an insurer claims that a treatment is excluded under the terms of the policy, that may require legal analysis rather than independent medical review. Similarly, if an insurance company engages in unreasonable delays, misrepresents policy provisions, or repeatedly requests documents it already possesses, those issues may support a bad faith claim even if an IMR is unavailable.
How Does the IMR Process Work?
The IMR process begins after the policyholder files an application with the appropriate state agency. The insurance company must provide all relevant records, including medical documentation, correspondence, and the basis for its denial. The state then assigns the matter to an independent review organization composed of qualified medical professionals.
The reviewers analyze the evidence according to accepted medical standards and issue their recommendations. Importantly, the insurance company does not control the reviewers or their conclusions. The purpose of the process is to provide an objective assessment of whether the requested treatment should be covered. If the independent reviewers determine that the treatment is medically necessary or should not be considered experimental, the insurer must generally comply with that decision and provide coverage.
Why Are IMRs So Important?
The statistics demonstrate why Independent Medical Reviews have become such an important consumer protection tool. According to the California Department of Managed Health Care’s 2024 annual report, approximately 53% of standard IMR determinations resulted in the health plan’s denial being overturned. In other words, more than half of the disputed denials reviewed through the IMR process were found to be improper. These numbers suggest that insurance companies do not always get medical necessity determinations right the first time.
The high reversal rate has also fueled broader discussions about insurer accountability and the need for greater transparency in claims handling and utilization review practices. California lawmakers and regulators have increasingly focused on the frequency with which independent reviewers disagree with insurers’ original decisions.
When an IMR Victory Does Not End the Problem
Unfortunately, obtaining a favorable IMR decision does not always mean the insurer immediately complies. The DMHC has taken enforcement actions against health plans that failed to timely implement IMR decisions after their denials were overturned. California law generally requires plans to authorize services or reimburse members promptly following a successful review. An insurer’s failure to comply with an IMR ruling can create additional legal issues and may provide evidence of unreasonable claims practices.
Likewise, some insurers engage in conduct that goes beyond ordinary coverage disputes. Repeated delays, unsupported denials, reliance on outdated medical guidelines, or efforts to wear down policyholders through endless administrative hurdles may constitute insurance bad faith under California law.
The Relationship Between IMRs and Bad Faith Claims
An Independent Medical Review is not the same thing as a bad faith lawsuit. The IMR process focuses on whether the medical decision was correct. A bad faith claim, on the other hand, examines whether the insurer acted reasonably and fulfilled its duty of good faith and fair dealing. Sometimes, an insurer simply makes the wrong medical judgment. In other situations, the denial reflects broader problems, such as inadequate investigations, cost-driven decision-making, or systemic practices that place profits ahead of patient care. An IMR determination overturning a denial can be powerful evidence that the insurer’s position lacked merit. Depending on the circumstances, additional legal remedies may also be available.
Frequently Asked Questions About IMRs
What is an Independent Medical Review in California?
An Independent Medical Review is a process that allows independent medical experts to review certain health insurance denials involving medical necessity, experimental treatments, or emergency care.
How often are health insurance denials overturned through IMRs?
According to the California Department of Managed Health Care’s 2024 data, approximately 53% of standard IMR decisions overturned the health plan’s denial and required coverage for the requested treatment.
Do I have to appeal through my insurance company before requesting an IMR?
Usually, yes. However, expedited reviews may be available when delaying treatment could seriously threaten the patient’s health or cause substantial harm.
Can an IMR help with a life insurance claim denial?
No. Independent Medical Reviews generally apply to health insurance disputes involving medical necessity and do not address life insurance claims or contractual coverage issues.
Can I still have a bad faith claim if I win an IMR?
Potentially, yes. If the insurer acted unreasonably, delayed care, ignored evidence, or engaged in unfair claims practices, additional legal remedies beyond the IMR process may be available.
Contact Gianelli & Morris
If your health insurance company denied treatment as medically unnecessary, experimental, or investigational, an Independent Medical Review may provide an opportunity to overturn that decision. But an IMR is only one part of protecting your rights as a policyholder. At Gianelli & Morris, we have decades of experience helping Californians fight wrongful health insurance denials and holding insurers accountable for bad faith conduct. We understand both the administrative review process and the legal remedies available when insurance companies fail to act fairly.
If your health plan has denied medically necessary care or engaged in unreasonable claims practices, contact Gianelli & Morris today for a free consultation to discuss your options and learn how we can help.
