Biofeedback for GU/ Kidney Disorder: 33.3% of denials overturned
In 12 California IMR decisions from 2002 to 2022, reviewers overturned 4 (33.3%). In the last five years: 100.0% of 2. 1 were medical-necessity disputes, 11 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2022 | 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. | 5 | 40.0% | 33.3% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 3 | 0.0% | 33.3% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 100.0% | 33.3% |
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: An enrollee has requested reimbursement for biofeedback services. Biofeedback has been shown to be beneficial to the treatment of patients with urinary problems when used as supplemental therapy. In addition, data from peer-reviewed medical literature reports that biofeedback can be beneficial for patients who have failed other treatment. In this case, the patient was being …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for biofeedback therapy. Rao and Patcharatrakul note that dyssynergic defecation is common and affects up to one-half of patients with chronic constipation. The authors further note that biofeedback therapy is recommended as the first-line of treatment for dyssynergic defecation. Lee and colleagues report that patients with abnormal contractions …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback (CPT code 90911). Urinary incontinence is a medical condition that significantly reduces quality of life. Nonsurgical therapy for urinary incontinence is recommended by specialists in urogynecology. Effective first-line treatment options supported in the medical literature include biofeedback techniques. Biofeedback has been shown to reduce symptoms and …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for biofeedback therapy. The long-term efficacy of biofeedback in addition to standard pelvic floor pelvic therapy for management of patients with urinary incontinence remains unknown. A recent randomized trial concluded that, “this preliminary study suggests that pelvic floor muscle training, with and without biofeedback, is …”
- 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 GU/ Kidney Disorder overturned?
In 12 California IMR decisions from 2002 to 2022, reviewers overturned 4 (33.3%). In the last five years: 100.0% of 2. 1 were medical-necessity disputes, 11 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.