Anti-Fungal for Infectious Disease: 52.6% of denials overturned
In 57 California IMR decisions from 2002 to 2024, reviewers overturned 30 (52.6%). In the last five years: 75.0% of 8. 55 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 100.0% |
| 2023 | 1 | 0.0% |
| 2024 | 5 | 80.0% |
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. | 8 | 62.5% | 52.6% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 50.0% | 52.6% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 5 | 80.0% | 52.6% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 0.0% | 52.6% |
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: A patient has requested reimbursement and prospective authorization and coverage for Jublia. The records document success with the past use of Jublia, supporting its efficacy for this patient’s condition. Given that the patient continues to require effective treatment for onychomycosis, the chronic nature of the condition, and the failure of …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cresemba. The records provided for review support a diagnosis of disseminated pulmonary and joint coccidioidomycosis. The patient was started on Cresemba since he failed treatment with the first-line antifungal, fluconazole, due to severe, progressive drug-related side effects. Thus, the patient requires treatment …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Posaconazole DR. The requested posaconazole delayed-release tablet is medically necessary for the treatment of this patient’s disseminated pulmonary coccidioidomycosis. As noted in the records provided for review, this patient’s pulmonary coccidioidomycosis has been refractory to prolonged treatment with high doses of fluconazole …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Jublia. This patient has a history of onychomycosis of the toenails, with culture results showing Penicillium, which is a non-dermatophyte. While Jublia is U.S. Food and Drug Administration (FDA)-approved for onychomycosis of the toenails, it is only FDA-approved for the treatment of …”
- 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 Infectious Disease overturned?
In 57 California IMR decisions from 2002 to 2024, reviewers overturned 30 (52.6%). In the last five years: 75.0% of 8. 55 were medical-necessity disputes, 2 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.