Breast Surgery for OB-GYN/ Pregnancy: 41.7% of denials overturned
In 24 California IMR decisions from 2002 to 2017, reviewers overturned 10 (41.7%). 22 were medical-necessity disputes, 1 experimental/investigational, 1 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 33.3% | 41.7% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 100.0% | 41.7% |
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
“A 46-year-old female enrollee has requested breast reduction surgery for treatment of her macromastia. Findings: The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. In this case, the patient’s large breasts hang down touching her pants which constitutes an abnormal structure of the body caused by a developmental abnormality. The …”
“A 64-year-old female enrollee requested magnetic resonance imaging (MRI) of the breasts for medical evaluation and treatment. Findings: Three physician reviewers found that the patient underwent removal of bilateral breast implants and replacement of the implants due to right implant rupture. According to the provider, a breast ultrasound demonstrated rupture of right breast implant and free silicone. Magnetic resonance imaging …”
“A 49-year-old female enrollee has requested a bilateral mastectomy for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the requested services in this patient’s case. This patient has a strong family history that puts her at elevated risk for developing breast cancer. Diagnostic mammography on the said date revealed bilateral dense breast tissue …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction surgery. The Health Plan has denied this request indicating that the requested for treatment of the enrollee’s bilateral symptomatic macromastia. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records document evidence of symptomatic …”
- 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 OB-GYN/ Pregnancy overturned?
In 24 California IMR decisions from 2002 to 2017, reviewers overturned 10 (41.7%). 22 were medical-necessity disputes, 1 experimental/investigational, 1 urgent care.
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.