Acupuncture for Digestive System/ GI: 40.0% of denials overturned
In 5 California IMR decisions from 2007 to 2022, reviewers overturned 2 (40.0%). In the last five years: 100.0% of 1. 4 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly acupuncture for two to three months. On review of the available documentation, this patient presents with interstitial cystitis. The patient has undergone treatment with physical therapy, medications, as well as modifications in her diet without adequate relief of her symptoms. The patient’s provider has recommended treatment …”
“Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for acupuncture. In investigating the efficacy of acupuncture for acute migraine attacks, the researchers found the results suggested acupuncture was effective in relieving pain and reducing the usage of acute medication. Researcher noted, “Acupuncture seems to be at least as effective as conventional drug preventative therapy for migraine and …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested acupuncture for treatment of the enrollee’s abdominal pain. Findings: Two physician reviewers found that this patient has been referred for treatment with acupuncture to possibly help with abnormal gut sensations during feedings. According to the provider’s notes, this is the presumed reason the patient is uncomfortable during feeding, …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Acupuncture denials for Digestive System/ GI overturned?
In 5 California IMR decisions from 2007 to 2022, reviewers overturned 2 (40.0%). In the last five years: 100.0% of 1. 4 were medical-necessity disputes, 1 experimental/investigational.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.