Allergy Testing for Skin Disorders: 50.0% of denials overturned
In 6 California IMR decisions from 2016 to 2023, reviewers overturned 3 (50.0%). In the last five years: 0.0% of 1. 2 were medical-necessity disputes, 4 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for allergy testing. Given the history and physical examination findings noted in the medical records, the likely diagnosis for this patient’s skin condition is atopic dermatitis (AD). There is adequate evidence in the medical literature to support testing for foods to help determine the aggravators of the underlying …”
“Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement for the allergy testing performed. Findings: The physician reviewer found that In the case of the patient, serum IgE testing for food hypersensitivity can be an appropriate test for evaluating atopic dermatitis according to the standard guidelines for the diagnosis and management of food allergy and …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested allergy testing for evaluation of her medical condition. Findings: The physician reviewer found that the medical records fail to indicate any diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease and the Joint Task Force on Practice Parameters for the Allergy …”
And one the reviewer upheld
“The physician reviewer found that An enrollee has requested reimbursement for a cellular function assay test.Findings: Three out of three physician reviewers found that the services at issue were not likely to have been more beneficial than any other available standard therapy for the patient's condition.Evaluation of a patient with chronic spontaneous urticaria should involve consideration of various possible causes, …”
- 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 Allergy Testing denials for Skin Disorders overturned?
In 6 California IMR decisions from 2016 to 2023, reviewers overturned 3 (50.0%). In the last five years: 0.0% of 1. 2 were medical-necessity disputes, 4 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.