Breast reduction for OB-GYN/ Pregnancy: 58.8% of denials overturned
In 51 California IMR decisions from 2002 to 2019, reviewers overturned 30 (58.8%). 51 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 9 | 33.3% | 58.8% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 7 | 85.7% | 58.8% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 75.0% | 58.8% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 33.3% | 58.8% |
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 reduction mammoplasty and panniculectomy. This patient presents with evidence of significant symptomatic bilateral macromastia that has failed reasonable conservative management. She has evidence of chronic neck, back and shoulder pain, as well as shoulder grooving and breast pain, which limit her daily activity. She has also a history …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage reduction mammoplasty for treatment of the enrollee's mammary hypertrophy. Findings: The physician reviewer found that the request for reduction mammaplasty is medically necessary for treatment of the patient’s medical condition. According to the guidelines from the American Society of Plastic Surgeon (ASPS), reduction mammaplasty has …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast reduction surgery for treatment of the enrollee, who has a history of back, neck, and shoulder pain due to her enlarged breasts. Findings: The physician reviewer found that the submitted documentation supports the medical necessity for the requested services in this clinical setting. The photographs submitted show evidence of …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction, including the removal of fat, glandular tissue, and skin. The submitted documentation does not support that the requested services are medically necessary. Breast implants are not an abnormal structure of the body, and excess breast weight from breast implants is not the result of a …”
- 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 OB-GYN/ Pregnancy overturned?
In 51 California IMR decisions from 2002 to 2019, reviewers overturned 30 (58.8%). 51 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.