Acupuncture for Immuno Disorders: 25.0% of denials overturned
In 8 California IMR decisions from 2002 to 2016, reviewers overturned 2 (25.0%). 6 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage and continuation of acupuncture services for treatment of the enrollee’s chronic pain. Findings: The physician reviewer found that there is sufficient support for a portion of the services at issue. In reviewing the records available, it does not appear that the patient had an acupuncture trial prior …”
“The patient is a 45-year-old female diagnosed as having fibromyalgia for approximately one and a half years. She first began treatment for this condition in July 2004 and received treatment until May 2005. The patient indicates she had symptoms six months prior to beginning acupuncture treatment. A request has been made for continued acupuncture and trigger point injections, which has …”
And one the reviewer upheld
“A 59-year-old male enrollee has requested eye movement desensitization and reprocessing (EMDR) therapy for treatment of his behavioral health condition. Findings: The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. EMDR is a therapy in which patients generate exposure to trauma via imagery while performing horizontal saccadic eye …”
- 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 Immuno Disorders overturned?
In 8 California IMR decisions from 2002 to 2016, reviewers overturned 2 (25.0%). 6 were medical-necessity disputes, 2 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.