Breast Surgery for Orth/Musculoskeletal: 66.7% of denials overturned
In 6 California IMR decisions from 2002 to 2018, reviewers overturned 4 (66.7%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“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 …”
“A 45-year-old female enrollee has requested bilateral reduction and extended panniculectomy and abdominoplasty for treatment of her excess skin and fat. Findings: The physician reviewer found that based on the records provided, the patient’s condition constitutes an abnormal structure of the body. Given the previous authorization for surgery and records from the treating surgeon indicating macromastia symptoms dating back to …”
“A thirty-six year-old female who has breast hypertrophy is requesting authorization of bilateral reduction mammoplasty. Reviewer’s Findings: The reviewing physician found that reduction mammoplasty provides the best and perhaps only chance for relief of this patient’s symptoms. The reviewing physician found that the Health Plan denial should be overturned.”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast augmentation revision/reduction surgery with modifier 50, performed treatment of the enrollee, who reported lower back pain and pain between her ribs. Findings: The physician reviewer found that the patient had undergone revision of her previous augmentation with placement of smaller implants and a mastopexy. Although the patient is …”
- 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 Orth/Musculoskeletal overturned?
In 6 California IMR decisions from 2002 to 2018, reviewers overturned 4 (66.7%). 6 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.