Analgesics denials: 20.1% overturned by independent reviewers
In 179 California IMR decisions from 2002 to 2017, reviewers overturned the plan 36 times (20.1%). 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 | 93 | 21.5% | — |
| CNS/ Neuromusc Dis | 25 | 32.0% | — |
| Chron Pain Synd | 22 | 13.6% | — |
| Immuno Disorders | 14 | 14.3% | — |
| Digestive System/ GI | 5 | 20.0% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 67 | 19.4% | 20.1% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 46 | 6.5% | 20.1% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 20 | 65.0% | 20.1% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 6 | 50.0% | 20.1% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 6 | 16.7% | 20.1% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 6 | 16.7% | 20.1% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone three times per day and Norco for treatment of the enrollee’s chronic pain due to fibromyalgia and cervical and lumbar radiculopathy. Findings: The physician reviewer has found based on the presented clinical records, the request for methadone and Norco are medically necessary for treatment of the …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 15 mg, four times per day for treatment of his chronic pain. Findings: The physician reviewer found that the Centers for Disease and Control and Prevention (CDC) guidelines suggest that chronic opiate maintenance is associated with elevated risks. The CDC also indicate that a consultation with …”
“Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Kadian 30 mg. Findings: The physician reviewer found that the records provided for review document that this patient has failed conservative treatments in an attempt to control her chronic abdominal pain secondary to pancreatitis. In particular, the patient has tried and failed several non-opioid medications, epidural steroid …”
- 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 Analgesics denials overturned?
In 179 California IMR decisions from 2002 to 2017, reviewers overturned the plan 36 times (20.1%).
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.