Anti-Fungal for Ears/Nose/Throat: 16.7% of denials overturned
In 6 California IMR decisions from 2003 to 2020, reviewers overturned 1 (16.7%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“A 50-year-old male enrollee has requested for continued treatment with Sporanox (itraconazole) for treatment of his sinusitis. Findings: The physician reviewer found that it is believed that some cases of chronic rhinosinusitis may be the result of nasal colonization with fungi combined with an allergic reaction to fungal antigens. It is not clear how often this occurs, but it is …”
And one the reviewer upheld
“The patient has requested reimbursement for posaconazole 300 mg by mouth daily for 30 days. This patient has a history of cough, shortness of breath, rhinitis, and chronic maxillary sinusitis. Posaconazole is reserved for invasive fungal sinusitis, which generally occurs in severely immunocompromised patients. The medical literature does not support the use of posaconazole for patients with mild CT findings …”
- 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 Anti-Fungal denials for Ears/Nose/Throat overturned?
In 6 California IMR decisions from 2003 to 2020, reviewers overturned 1 (16.7%). 6 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.