Analgesics for Orth/Musculoskeletal: 21.5% of denials overturned
In 93 California IMR decisions from 2002 to 2017, reviewers overturned 20 (21.5%). 93 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. | 38 | 26.3% | 21.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 21 | 9.5% | 21.5% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 9 | 77.8% | 21.5% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 6 | 16.7% | 21.5% |
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 OxyContin 60 mg, Flexeril 10 mg, Percocet 10/325 and a referral to a spine surgeon for treatment of her back pain. Findings: The physician reviewer found that the patient has inconsistent urine toxicology testing as well as unauthorized self-escalation of her opiate medications. She has violated the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine for treatment of the enrollee's pain. Findings: The physician reviewer has found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient is not following the opiate maintenance agreement, and the urine toxicology screens are inconsistent with the prescription. Therefore, …”
- 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 Orth/Musculoskeletal overturned?
In 93 California IMR decisions from 2002 to 2017, reviewers overturned 20 (21.5%). 93 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.