Analgesic Rx denials: 18.5% overturned by independent reviewers
In 65 California IMR decisions from 2005 to 2017, reviewers overturned the plan 12 times (18.5%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Orth/Musculoskeletal | 28 | 7.1% | — |
| Chron Pain Synd | 19 | 42.1% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 22 | 13.6% | 18.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 21 | 0.0% | 18.5% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 8 | 37.5% | 18.5% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 0.0% | 18.5% |
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 authorization and coverage for Norco and Diazepam for treatment of the enrollee’s chronic low back pain. Findings: The physician reviewer has found that based on the documentation submitted for review, the patient has had long-term opioid use and has been prescribed benzodiazepines medication on a long-term basis. He describes symptoms of …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 50 mg capsules for treatment of the enrollee who has a history of myofascial muscle pain, fibromyalgia, and lumbago. Findings: The physician reviewer found that The medical literature supports the requested medication in this clinical setting. Specifically, the patient’s WPI score was noted to be greater …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lotronex (alosetron hydrochloride) and Subutex (buprenorphine) for treatment of the enrollee’s chronic pain and irritable bowel syndrome (IBS). Findings: The physician reviewer found that the records provided document a diagnosis of opioid dependence. Thus, Subutex is medically appropriate for this patient. For these reasons, the requests 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 Analgesic Rx denials overturned?
In 65 California IMR decisions from 2005 to 2017, reviewers overturned the plan 12 times (18.5%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.