Biopsy for Skin Disorders: 40.0% of denials overturned
In 5 California IMR decisions from 2010 to 2022, reviewers overturned 2 (40.0%). In the last five years: 50.0% of 2. 5 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal and/or biopsy of skin lesions. For approaching melanocytic lesions, criteria such as the algorithm presented by the American Academy of Dermatology (AAD), and evaluation of gross features such as bleeding, pain, and growth, are critical (Tsao, et al.). The AAD algorithm for the evaluation of nevi …”
“A 24-year-old male enrollee has requested a biopsy of penile papules for treatment of his medical condition. Findings: The physician reviewer found that this patient presents with penile lesions of unknown etiology. While sebaceous gland hyperplasia is suspected, other possible causes have not been excluded. The lesions may be due to human papillomavirus infection. Although the STD work-up was normal, …”
And one the reviewer upheld
“The physician reviewer found that The parents of an enrollee has requested authorization and coverage for dermatology services (including office visit and biopsies) at a clinic offering pediatric tertiary care.Removal of benign nevi for biopsy is a very common procedure that is performed by all dermatologists. Cohen states, “Most dermatologists evaluate children and adolescents who have changing moles. Moreover, most …”
- 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 Biopsy denials for Skin Disorders overturned?
In 5 California IMR decisions from 2010 to 2022, reviewers overturned 2 (40.0%). In the last five years: 50.0% of 2. 5 were medical-necessity disputes.
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.