Acupuncture for Mental Disorder: 50.0% of denials overturned
In 6 California IMR decisions from 2004 to 2020, reviewers overturned 3 (50.0%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“This patient is a 28-year-old female who has a history of neck, shoulder and back pain apparently related to an injury three years ago. She also experiences headaches and stress and anxiety possibly related to the injury. Furthermore, the patient has complaints of pre-menstrual syndrome and menstrual symptoms. It is also noted from the submitted records that the patient experiences …”
“The patient is a 31-year-old female who reports a long-standing history of panic attacks, anxiety disorder, and minor depression. Since the birth of her child, the patient reports her panic attacks, anxiety disorder, and depression have increased. She reports experiencing approximately three episodes a day. The patient’s physician attributes the increase in part to increased hormone levels as well as …”
“The patient reports a history of anxiety/tension and menstrual cramps. She indicates she has been experiencing anxiety since her last two miscarriages. The patient has a strong desire to become pregnant and to avoid a miscarriage. She is concerned about the risks associated with anti-anxiety medications. It appears the patient has benefited from an acupuncture treatment she previously received. A …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 1 additional acupuncture session (3 total per month). Researchers noted that the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management …”
- 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 Mental Disorder overturned?
In 6 California IMR decisions from 2004 to 2020, reviewers overturned 3 (50.0%). 6 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.