Birth Control for OB-GYN/ Pregnancy: 18.2% of denials overturned
In 11 California IMR decisions from 2003 to 2018, reviewers overturned 2 (18.2%). 9 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Yaz for treatment of her bleeding with other birth control medications. Findings: The physician reviewer found that for the symptoms that the patient has described, most oral contraceptive pills will improve her symptoms. However, there is evidence that those oral contraceptive pills with drospirenone are superior for …”
“A 32-year-old female enrollee has requested Mirena IUD for the treatment of her menorrhagia. Findings: Three physician reviewers found that Mirena IUD has been demonstrated to be effective in the treatment of menorrhagia. It can also be useful for dysmenorrhea. This patient cannot tolerate birth control pills. The requested IUD is likely to be more successful for this patient than …”
And one the reviewer upheld
“The physician reviewer found that an enrollee has requested authorization and coverage for Lupin levonorgestrel and ethinyl estradiol tablets USP 0.1mg for birth control due to a diagnosis of Polycystic Ovarian Syndrome. There is a place for deference to branded birth control pills and the American College of Obstetrics and Gynecology has addressed this issue. The medical issue for why …”
- 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 Birth Control denials for OB-GYN/ Pregnancy overturned?
In 11 California IMR decisions from 2003 to 2018, reviewers overturned 2 (18.2%). 9 were medical-necessity disputes, 2 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.