C-Pap Machine for Respiratory System: 50.0% of denials overturned
In 48 California IMR decisions from 2002 to 2018, reviewers overturned 24 (50.0%). 46 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 11 | 63.6% | 50.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 12.5% | 50.0% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 4 | 75.0% | 50.0% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 50.0% |
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: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) device (CPT code E0601). The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee’s obstructive sleep apnea. The submitted documentation supports the medical necessity of the requested device. Based on …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) device. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee’s obstructive sleep apnea. A review of the submitted records indicates that the enrollee has been diagnosed with obstructive sleep …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) machine. As noted in the current medical literature, CPAP is recommended as the first-line treatment for patients with OSA. Further, the American College of Physicians (ACP) support CPAP as “initial therapy for patients diagnosed with OSA” and note that this recommendation …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for CPAP (continuous positive airway pressure) device and supplies. The Health Plan has denied this request indicating that the requested equipment and supplies were not and are not medically necessary for treatment of the enrollee’s sleep apnea.At issue in this case is whether the CPAP …”
- 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 C-Pap Machine denials for Respiratory System overturned?
In 48 California IMR decisions from 2002 to 2018, reviewers overturned 24 (50.0%). 46 were medical-necessity disputes, 2 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.