Anti-inflammatories for CNS/ Neuromusc Dis: 55.6% of denials overturned
In 9 California IMR decisions from 2017 to 2023, reviewers overturned 5 (55.6%). In the last five years: 33.3% of 3. 9 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 2 | 0.0% |
| 2023 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 50.0% | 55.6% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 50.0% | 55.6% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 3 | 66.7% | 55.6% |
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 The patient has requested authorization and coverage for Acthar Gel 80 units/mL administered daily for two weeks. As noted in the medical literature, the recommended first-line therapy for patients with acute exacerbations of multiple sclerosis has been high-dose corticosteroid therapy. The U.S. Food and Drug Administration (FDA) has approved Acthar Gel for the treatment of …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tysabri infusions. Multiple sclerosis is a progressive condition which leads to worsening neurological disability. Researcher describes natalizumab as the first humanized monoclonal antibody indicated in the treatment of relapsing-remitting multiple sclerosis (RRMS). The researcher noted natalizumab was indicated in active RRMS based on its remarkable efficacy in …”
“Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for H.P. Acthar gel injections. The enrollee has multiple sclerosis. The medical records report the enrollee has experienced severe acute, debilitating exacerbations of this disease, negatively impacting his physical and mental health and quality of life. The enrollee has experienced worsening fatigue, heat intolerance, decreased range of …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the rituximab (Rituxan) infusions. The records provided for review document that this patient was recently diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). As noted in the medical literature, CIDP is an acquired, immune-mediated neuropathy affecting a patient’s peripheral nerves and nerve roots. The patient has been treated …”
- 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-inflammatories denials for CNS/ Neuromusc Dis overturned?
In 9 California IMR decisions from 2017 to 2023, reviewers overturned 5 (55.6%). In the last five years: 33.3% of 3. 9 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.