Acupuncture for Ears/Nose/Throat: 63.6% of denials overturned
In 11 California IMR decisions from 2002 to 2022, reviewers overturned 7 (63.6%). In the last five years: 100.0% of 1. 11 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 7 | 57.1% | 63.6% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“The physician reviewer found that The patient has requested authorization and coverage for acupuncture services. While conventional medicine has not yet developed effective treatments or clinical practice guidelines for the treatment of long COVID-19 due to the new and evolving nature of the condition and limited number of cases, current medical literature does support the use of acupuncture for the …”
“Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for traditional acupuncture with electrostimulation. Review of the submitted documentation supports the medical necessity of the requested services. The provider has recommended traditional acupuncture with electrostimulation for treatment of the patient’s laryngeal spasm and dysphonia. Based upon the documentation provided, this appears to be an initial trial of …”
“Nature of Statutory Criteria/Case Summary: A 29-year-old male enrollee has requested authorization and coverage for acupuncture for treatment of Tinnitus. Findings: The physician reviewer found that Tinnitus is a subjective sensation of hearing a sound in the absence of an external stimulus, which significantly worsens the quality of life of affected patients. A recent randomized clinical trial demonstrated the effects …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture for treatment of the enrollee’s tinnitus.Findings: The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The studies that support acupuncture as an effective therapy for chronic tinnitus are not based on evidence …”
- 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 Ears/Nose/Throat overturned?
In 11 California IMR decisions from 2002 to 2022, reviewers overturned 7 (63.6%). In the last five years: 100.0% of 1. 11 were medical-necessity disputes.
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.