Breast Surgery for Endocrine/Metabolic: 18.2% of denials overturned
In 11 California IMR decisions from 2006 to 2017, reviewers overturned 2 (18.2%). 11 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). | 3 | 0.0% | 18.2% |
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: EE requested authorization and coverage bilateral removal of gynecomastia. Findings: The physician reviewer found that the request for bilateral removal of gynecomastia is medically necessary for treatment of the patient’s medical condition. The patient presents with bilateral symptomatic gynecomastia without resolution despite attempted weight loss. Work-up of the bilateral masses and possible correctable causes had …”
“A 27-year-old male enrollee has requested for a bilateral breast reduction/lump removal for treatment of his gynecomastia. Findings: The physician reviewer found that this patient’s tender gynecomastia has a clinically significant impact on his activities of daily life. Moreover, the tissue involved is glandular in nature.”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the removal of tissue from the breasts performed for treatment of the enrollee’s gynecomastia. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. The patient’s pain and discomfort is not adequately supported in …”
- 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 Endocrine/Metabolic overturned?
In 11 California IMR decisions from 2006 to 2017, reviewers overturned 2 (18.2%). 11 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.