Anti-virals for Immuno Disorders: 16.7% of denials overturned
In 6 California IMR decisions from 2004 to 2020, reviewers overturned 1 (16.7%). 5 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 16.7% |
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
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for budesonide extended release, 3 mg. The American Association for the Study of Liver Diseases (AASLD) support treatment with budesonide as a first-line corticosteroid therapy for patients with autoimmune hepatitis. The AASLD guidelines cite a lower risk of systemic side effects such as myalgias with budesonide than prednisone. …”
And one the reviewer upheld
“The patient has requested authorization and coverage for valganciclovir one to two weeks a month every three months x 2, gammaglobulin injections, antivirals for HSV 6 gastrointestinal infection, and/or voriconazole for 30 days. The patient’s records report a variety of non-specific symptoms including fatigue, headache, and neck pain. There is a lack of clinical findings consistent with a diagnosis 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-virals denials for Immuno Disorders overturned?
In 6 California IMR decisions from 2004 to 2020, reviewers overturned 1 (16.7%). 5 were medical-necessity disputes, 1 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.