Analgesics for Chron Pain Synd: 13.6% of denials overturned
In 22 California IMR decisions from 2009 to 2017, reviewers overturned 3 (13.6%). 21 were medical-necessity disputes, 1 experimental/investigational.
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 | 8.3% | 13.6% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 0.0% | 13.6% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 66.7% | 13.6% |
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 OxyContin 30 mg and OxyContin 40 mg for the treatment of the enrollee’s chronic pain. Findings: The physician reviewer found that the patient is on high dose opiates for post-laminectomy syndrome. The Health Plan has denied coverage for OxyContin 30 mg and OxyContin 40 mg. However, the patient was left without …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Opana ER for treatment of her medical condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient has a chronic pain diagnosis, which has been treated with a number of modalities, and multiple narcotic and non-narcotic pain medications. Researchers report that for chronic non-cancer pain, …”
“A 38-year-old female enrollee has requested Lyrica for the treatment of her nerve entrapment secondary to abdominoplasty. Findings: The physician reviewer found that neuropathic pain is a condition developed after nerve injury, either central or peripheral, has occurred. It is often associated with poor response to conventional treatments. Anticonvulsants such as gabapentin and Lyrica have shown statistically significant success in …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increase in dosage of fentanyl from 175 mcg to fentanyl 250 mcg for treatment of her fibromyalgia, neuropathy, and bilateral sacroiliac joint dysfunction. Findings: The physician reviewer found that in this clinical setting, the recommendation to maintain the patient’s pain medications at 175 mcg is well …”
- 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 for Chron Pain Synd overturned?
In 22 California IMR decisions from 2009 to 2017, reviewers overturned 3 (13.6%). 21 were medical-necessity disputes, 1 experimental/investigational.
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.