Ambulance/Transport for Trauma/ Injuries: 75.0% of denials overturned
In 8 California IMR decisions from 2006 to 2016, reviewers overturned 6 (75.0%). 6 were medical-necessity disputes, 2 urgent care.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance transport services provided from California to Illinois for treatment of the enrollee’s traumatic brain injury following a high speed motor vehicle collision. Findings: The physician reviewer found the air ambulance transport services were medically necessary for treatment of the patient’s medical condition. Medical monitoring can minimize health …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested air ambulance transport services for treatment of the enrollee, who sustained a traumatic brain injury. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient had multiple significant and life-threatening injuries as a result of a motor vehicle …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air and ground ambulance transportation services for treatment of the enrollee’s traumatic brain jury. Findings: The physician reviewer found that the air ambulance and ground ambulance transportation services were medically necessary for treatment of the patient’s medical condition. In this case, the patient sustained a brain injury and hip …”
And one the reviewer upheld
“A male enrollee requested air ambulance transport services on an emergent basis. Findings: The physician reviewer found that air ambulance is indicated under certain circumstances. However, in such circumstances, the transport is covered to the closest facility capable of providing adequate care. This patient was not transferred to the closest facility capable of providing care. Although the patient required continued …”
- 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 Trauma/ Injuries overturned?
In 8 California IMR decisions from 2006 to 2016, reviewers overturned 6 (75.0%). 6 were medical-necessity disputes, 2 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.