Anti-inflammatories for Foot Disorder: 40.0% of denials overturned
In 5 California IMR decisions from 2008 to 2018, reviewers overturned 2 (40.0%). 5 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for diclofenac sodium 1% gel. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s posterior tibial tendinitis with plantar fasciitis secondary to pathomechanics. The submitted documentation supports the medical necessity of the requested medication. The current …”
“A 50-year-old female enrollee has requested Voltaren 1% gel for the treatment of her bilateral tarsal tunnel syndrome. Findings: The physician reviewer found that Voltaren gel is a topical presentation of diclofenac, a nonsteroidal anti-inflammatory drug (NSAID) and is indicated for the relief of osteoarthritis of the joints amenable to topical treatment. Voltaren’s mechanism of action is related to the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested colchicine tablet for treatment of the enrollee, who has a history of gout. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The guidelines recommends that patients use nonsteroidal anti-inflammatory drugs, rather than colchicine or glucocorticoids, as first-line therapy for most …”
- 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 Foot Disorder overturned?
In 5 California IMR decisions from 2008 to 2018, reviewers overturned 2 (40.0%). 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.