Anti-Fungal for Foot Disorder: 30.0% of denials overturned
In 20 California IMR decisions from 2003 to 2024, reviewers overturned 6 (30.0%). In the last five years: 66.7% of 3. 20 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2024 | 2 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 3 | 0.0% | 30.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 33.3% | 30.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 30.0% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ciclopirox (Penlac), topical anti-fungal treatment. Onychomycosis can be challenging to treat due to the thickness of the nail plate. Researchers note that while oral medications have higher success rates than topical agents, oral treatments may also present challenges in cases of drug-to-drug …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jublia 10% topical solution. Findings: The physician reviewer found that Onychomycosis is a fungal infection of the nail which can result in pain, disfigurement, and secondary infection. Ulcerations of the nail bed as well as resultant osteomyelitis of the underlying phalanges may result, particularly in patients with …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Jublia medication for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Jublia is U.S. Food and Drug Administration (FDA) approved for the topical treatment of onychomycosis of the toenails due to Trichophyton rubrum and Trichophyton mentagrophytes. This …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jublia. Due to the thickness of the nail plate, onychomycosis can be difficult to treat. Recent review articles and meta-analyses indicate that oral medications are superior to topical agents for the treatment of onychomycosis. Specifically, oral terbinafine or itraconazole have been demonstrated to achieve the best cure …”
- 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 Foot Disorder overturned?
In 20 California IMR decisions from 2003 to 2024, reviewers overturned 6 (30.0%). In the last five years: 66.7% of 3. 20 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.