Biofeedback for Orth/Musculoskeletal: 45.5% of denials overturned
In 11 California IMR decisions from 2006 to 2018, reviewers overturned 5 (45.5%). 4 were medical-necessity disputes, 7 experimental/investigational.
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 | 20.0% | 45.5% |
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 authorization and coverage for biofeedback therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s pelvic floor dysfunction. The submitted documentation supports the requested services in this patient’s case. Research indicated that biofeedback therapy is effective in the long …”
“The parent of a 14-year-old female enrollee has requested biofeedback for treatment of the enrollee’s chronic back pain and headaches. Findings: Two physician reviewers found that studies for biofeedback have been difficult to perform in terms of a double blind study. Many of the published references are meta-analyses and reviews up to this point. That said, there have been a …”
“The parent of a 15-year-old female enrollee has requested biofeedback and self-care home management training with therapeutic (group) procedures for the treatment of the enrollee’s hypermobility and dysautonomia. Findings: Three physician reviewers found that this patient’s history documents pain since the age of six, consistent with symptoms associated with Ehlers-Danlos syndrome. The patient has not demonstrated adequate relief with prior …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback. Findings: Two of the three physician reviewers found the submitted documentation fails to demonstrate the superior efficacy of the requested services. Per the medical literature, there is a lack of evidence of efficacy for biofeedback in the treatment of chronic, non-specific, low back pain. There 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 Orth/Musculoskeletal overturned?
In 11 California IMR decisions from 2006 to 2018, reviewers overturned 5 (45.5%). 4 were medical-necessity disputes, 7 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.