Analgesics for Immuno Disorders: 14.3% of denials overturned
In 14 California IMR decisions from 2007 to 2017, reviewers overturned 2 (14.3%). 14 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 0.0% | 14.3% |
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 duloxetine HCL 60 mg three times per day for treatment of her neuropathic pain. Findings: The physician reviewer found that the medical records provided for review document specific antidepressant and anticonvulsant medications have been tried and failed or demonstrated untoward side effects. As such, the medical records …”
“A 63-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia and continued pelvic pain. Findings: The physician reviewer found that this patient has a chronic pain syndrome related to lumbar spine surgery. Several providers noted multiple trigger points and include a diagnosis of fibromyalgia. While the records do not outline a formal description that confirms a diagnosis …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of her medical condition. Findings: The physician reviewer found that the medical necessity of Norco is not established. The patient presents with non-malignant chronic pain which will often worsen or recur as a result of opioid rebound. The long-term use of high-dose short-acting opiates such as Norco has …”
- 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 Immuno Disorders overturned?
In 14 California IMR decisions from 2007 to 2017, reviewers overturned 2 (14.3%). 14 were medical-necessity disputes.
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.