Biofeedback for Digestive System/ GI: 73.7% of denials overturned
In 19 California IMR decisions from 2004 to 2022, reviewers overturned 14 (73.7%). In the last five years: 66.7% of 3. 11 were medical-necessity disputes, 8 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 3 | 66.7% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 100.0% | 73.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 75.0% | 73.7% |
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 pelvic floor program consisting of (rectal balloon biofeedback therapy) three times a day for one week, and twice a day for a second week. The records document that this patient presents with pelvic dyssynergia and possible anal fistula. Treatment has included surgery, but the patient reports continued …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for electrostimulation biofeedback physiotherapy (a total of six one-hour sessions). Electrostimulation biofeedback physiotherapy is a pelvic floor rehabilitation technique that is well supported in current medical literature for the treatment of urinary/fecal incontinence, pelvic pain, erectile dysfunction, defecatory disorders, and dyssynergic defecation. These techniques are largely designed to …”
“Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for genito-urinary biofeedback therapy. This enrollee was diagnosed with polyuria, chronic interstitial cystitis, and dyssynergia on. He reports urinary frequency, up to 20 times per day, and bladder pain. A cystoscopy did not show a reason for his symptoms. The enrollee reports he is unable to go …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) testing body biofeedback, (2) non-invasive vagus nerve stimulation, (3) electrical stimulation, and (4) vestibular rehabilitation. Findings: The physician reviewer found that the patient has multiple psychiatric diagnoses, but presents predominantly with somatic symptoms and without insight into his psychiatric diagnoses. While the patient has been evaluated …”
- 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 Biofeedback denials for Digestive System/ GI overturned?
In 19 California IMR decisions from 2004 to 2022, reviewers overturned 14 (73.7%). In the last five years: 66.7% of 3. 11 were medical-necessity disputes, 8 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.