Anti-Fungal for Skin Disorders: 40.0% of denials overturned
In 5 California IMR decisions from 2002 to 2021, reviewers overturned 2 (40.0%). In the last five years: 100.0% of 1. 5 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for itraconazole. Oral antifungals such as itraconazole are indicated for the treatment of onychomycosis and also severe, recalcitrant, or widespread fungal infections of the skin. The U.S. Food and Drug Administration (FDA) has approved itraconazole for the treatment of dermatophyte infections. In this patient’s clinical …”
“A twenty-nine year-old male with severe dermatitis is requesting authorization of a course of Sporanox. Reviewer’s Findings: The reviewing physician found that it is clear that the patient improved clinically while he was taking Sporanox. The reviewing physician found that the Health Plan denial should be overturned.”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Enbrel 50 mg twice weekly treatment of his psoriasis. Findings: The physician reviewer found that this patient presents with plaque psoriasis. He has shown good clinical response to Enbrel 50 mg twice weekly, but loses efficacy when dosed at the U.S. Food and Drug Administration (FDA) approved maintenance dose of 50 …”
- 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 Skin Disorders overturned?
In 5 California IMR decisions from 2002 to 2021, reviewers overturned 2 (40.0%). In the last five years: 100.0% of 1. 5 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.