Antibiotics for Respiratory System: 42.9% of denials overturned
In 7 California IMR decisions from 2003 to 2021, reviewers overturned 3 (42.9%). In the last five years: 100.0% of 1. 6 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that The patient has requested authorization and coverage for tobramycin 300 mg/5 mL inhalation solution/powder. Based on the available information, the requested tobramycin 300 mg/5 mL inhalation solution/powder is medically necessary for the management of this patient’s condition. Loebinger and colleagues reported that tobramycin “significantly reduced the P. aeruginosa sputum density from baseline to day 29 …”
“A 56-year-old female enrollee has requested continuous azithromycin (Zithromax) for the treatment of her bronchiolitis obliterans/constrictive bronchiolitis. Findings: The physician reviewer found that there are significant long-term complications of chronic steroids, and other anti-inflammatory agents should be tried. As macrolide antibiotics such as Zithromax have been shown to be helpful in eosinophilic bronchiolitis, a six-month trial of Zithromax is medically …”
“The patient is a 68-year-old female with bronchiectasis. According to the information provided the patient was diagnosed with bronchiectasis with mucoid pseudomonas infection by her pulmonologist. Thereafter, the patient was started on inhaled tobramycin after a hospitalization in December 2003. The patient’s condition improved after home treatment with inhaled tobramycin. The patient was also started on daily azithromycin as well …”
And one the reviewer upheld
“The parent of a 15-month-old female enrollee has requested Synagis to assist in the prevention of respiratory syncytial virus (RSV) infection. Findings: The physician reviewer found that while the patient was born prematurely, and as such has experienced some of the complications of premature birth, her respiratory disease does not meet the accepted definition of chronic lung disease (CLD) 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 Antibiotics denials for Respiratory System overturned?
In 7 California IMR decisions from 2003 to 2021, reviewers overturned 3 (42.9%). In the last five years: 100.0% of 1. 6 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.