Ambulance/Transport for Cardiac/Circ Problem: 37.5% of denials overturned
In 8 California IMR decisions from 2008 to 2017, reviewers overturned 3 (37.5%). 3 were medical-necessity disputes, 5 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 3 | 66.7% | 37.5% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance transportation services. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical air transportation for treatment of an emergency medical condition. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation …”
“An 89-year-old male enrollee has requested air ambulance transport for the treatment of him following a cerebral stroke. Findings: The physician reviewer found that the standard of care in facilities outside of the US is not generally known. Within the United States, it would be the norm for a patient to be treated by a licensed physician, preferably one knowledge …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested air ambulance transportation for treatment of his medical condition. Findings: The physician reviewer found that the air ambulance transportation has not been established as medically necessary in this clinical setting. Per the documentation submitted, a definitive diagnosis of an acute myocardial infarction was not made. In addition the ECG provided for …”
- 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 Ambulance/Transport denials for Cardiac/Circ Problem overturned?
In 8 California IMR decisions from 2008 to 2017, reviewers overturned 3 (37.5%). 3 were medical-necessity disputes, 5 urgent care.
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.