Breast Surgery denials: 40.3% overturned by independent reviewers
In 62 California IMR decisions from 2002 to 2018, reviewers overturned the plan 25 times (40.3%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| OB-GYN/ Pregnancy | 24 | 41.7% | — |
| Endocrine/Metabolic | 11 | 18.2% | — |
| Cancer | 7 | 71.4% | — |
| Orth/Musculoskeletal | 6 | 66.7% | — |
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). | 13 | 23.1% | 40.3% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 8 | 62.5% | 40.3% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 33.3% | 40.3% |
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: Nature of Statutory Criteria/Case Summary: Findings: The physician reviewer found that a review of the submitted documentation does not support the medical necessity of the requested services. The records indicate the patient has undergone appropriate evaluation for gender dysphoria according to 2017 Endocrine Society clinical practice guidelines. Based upon the most recent documentation provided, the …”
“Nature of Statutory Criteria/Case Summary: A 43-year-old female enrollee has requested authorization and coverage for reduction mammoplasty for their back pain. Findings: The physician reviewer found that Her symptoms include upper back and shoulder pain, as well as shoulder grooving seen on photographs. The photographs are supportive that her clinical condition and functional deficit of pain are likely directly related …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast Botox injections performed. In the peer-reviewed medical literature, it was reported that patients who were injected with Botox in the pectoral muscles in the time between mastectomy and tissue expander placement reported less postoperative pain and used fewer narcotics in the first 24 hours after surgery and …”
- 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 Surgery denials overturned?
In 62 California IMR decisions from 2002 to 2018, reviewers overturned the plan 25 times (40.3%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.