Breast reduction for Mental Disorder: 100.0% of denials overturned
In 10 California IMR decisions from 2017 to 2022, reviewers overturned 10 (100.0%). In the last five years: 100.0% of 2. 10 were medical-necessity disputes.
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. | 3 | 100.0% | 100.0% |
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 bilateral mastectomy and chest reconstruction surgery. Findings: The physician reviewer found that he World Professional Association for Transgender Health (WPATH) states, “Chest surgery in female-to-male patients could be carried out earlier [than 18], preferably after ample time of living in the desired gender role and after one …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mammoplasty. Findings: The physician reviewer found that World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that in the treatment of the male-to-female patient, surgical procedures in the treatment of gender dysphoria may include “breast/chest surgery: augmentation mammoplasty (implants/lipofilling)” (Coleman, et al.). The …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for suction assisted lipectomy (CPT code 15877). The World Professional Association for Transgender Health (WPATH) lists chest surgery, creation of a male chest, as a medically necessary treatment for gender dysphoria. Olson-Kennedy and colleagues reported that chest surgery is a safe and effective treatment for gender dysphoria, noting, “Chest dysphoria …”
- 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 Breast reduction denials for Mental Disorder overturned?
In 10 California IMR decisions from 2017 to 2022, reviewers overturned 10 (100.0%). In the last five years: 100.0% of 2. 10 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.