Analgesics for CNS/ Neuromusc Dis: 32.0% of denials overturned
In 25 California IMR decisions from 2005 to 2017, reviewers overturned 8 (32.0%). 24 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. | 7 | 14.3% | 32.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 0.0% | 32.0% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 5 | 60.0% | 32.0% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 33.3% | 32.0% |
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 Botox injections for treatment of her migraine headaches. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. The records support the diagnosis of chronic migraine. Botox has been shown to be beneficial for preventive treatment of chronic migraine, …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block injection for treatment of her chronic migraine. Findings: Three physician reviewers found that the request for occipital nerve block injection is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. The patient presents with a diagnosis …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Lyrica for treatment of her medical condition. Findings: The physician reviewer found that Lyrica is medically necessary for treatment of the patient’s medical condition. There is sufficient support in the evidence based literature supporting the requested services. Lyrica has been utilized off-label for many neuropathic pain syndromes. There is significant literature …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Lyrica 25 mg, three times per day for the treatment of the enrollee’s headaches. Findings: The physician reviewer found that Lyrica is an anticonvulsant medication that is U.S. Food and Drug Administration approved for the treatment of fibromyalgia, neuropathic pain associated with diabetic peripheral …”
- 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 CNS/ Neuromusc Dis overturned?
In 25 California IMR decisions from 2005 to 2017, reviewers overturned 8 (32.0%). 24 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.