Breast Surgery for Cancer: 71.4% of denials overturned
In 7 California IMR decisions from 2003 to 2018, reviewers overturned 5 (71.4%). 3 were medical-necessity disputes, 4 experimental/investigational.
What the findings mention
From recent overturned decisions
“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 …”
“A 60-year-old female enrollee has requested left breast reconstruction, abdominoplasty, and brachioplasty for treatment of her breast cancer. Findings: The physician reviewer found that cosmetic surgery is performed to reshape normal structures of the body in order to improve a patient’s appearance and self esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental …”
“A 41-year-old female enrollee has requested human acellular tissue matrix (AlloDerm) assisted breast reconstruction for the treatment of her breast reconstruction. Findings: Three physician reviewers found that AlloDerm has been FDA approved as banked human tissue with no specific indication or contraindication. Thus, a physician may use this product in any manner he reasonably desires or needs to use banked …”
And one the reviewer upheld
“A 63-year-old male enrollee has requested a right cutaneous mastectomy for treatment of his unilateral gynecomastia. Findings: The physician reviewer found that male breast cancer is quite rare. In a comprehensive review on the topic of enlarged male breasts, Volpe and others recommended evaluation of a mass with ultrasound and mammography followed by fine needle aspiration. Mammography can accurately distinguish …”
- 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 for Cancer overturned?
In 7 California IMR decisions from 2003 to 2018, reviewers overturned 5 (71.4%). 3 were medical-necessity disputes, 4 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.