Analgesic Rx for Orth/Musculoskeletal: 7.1% of denials overturned
In 28 California IMR decisions from 2005 to 2017, reviewers overturned 2 (7.1%). 25 were medical-necessity disputes, 2 experimental/investigational, 1 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 12 | 0.0% | 7.1% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 11 | 0.0% | 7.1% |
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
“A 50-year-old female enrollee has requested for Actiq 1600mcg for treatment of her cervical pain. Findings: The physician reviewer found that there is more experience with the use of opioids in the cancer population, and the long-term use and continuous efficacy of these medications in the non-malignant pain population is still a matter of debate. Even though the etiology of …”
“The patient is a 47-year-old male with chronic back pain and a history of opioid dependence. He has requested authorization and coverage for Subutex for pain control. The Health Plan has denied the patient’s request indicating the requested medication is not medically necessary for treatment of the patient’s condition.Review of the submitted clinical records documents a significant pain condition requiring …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco and Lidoderm patches for treatment of the enrollee’s lower back pain. Findings: The physician reviewer found that there is a lack of support for the medical necessity for the requested medications in this clinical setting. Chronic pain that has no hope for a cure is considered …”
- 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 for Orth/Musculoskeletal overturned?
In 28 California IMR decisions from 2005 to 2017, reviewers overturned 2 (7.1%). 25 were medical-necessity disputes, 2 experimental/investigational, 1 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.