Card Valve Repl denials: 73.9% overturned by independent reviewers
In 23 California IMR decisions from 2003 to 2023, reviewers overturned the plan 17 times (73.9%). In the last five years: 72.7% of 11. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Cardiac/Circ Problem | 23 | 73.9% | 72.7% of 11 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 100.0% |
| 2022 | 5 | 60.0% |
| 2023 | 4 | 75.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 66.7% | 73.9% |
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: The patient has requested authorization and coverage for mitral valve repair through right mini-thoracotomy robotic assistant, as well as the MAZE procedure. Robot-assisted minimally invasive mitral valve surgery (MIMVS) has become the least invasive approach to mitral valve surgery. MIMVS provides equivalent or superior results to those achieved via conventional operations in the following: in-hospital …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter trans-septal valve-in-valve replacement. In this case, the patient has severe symptomatic bioprosthetic mitral valve stenosis with no favorable medical management options. The patient’s surgical risk is prohibitive to redo surgical valve replacement. According to researchers, valve-in-valve replacement is considered a reasonable alternative for patients in similar …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter mitral valve repair using valve-in-valve (TMVI) repair. The current peer-reviewed medical literature demonstrates that the requested TMVI repair is an acceptable treatment option for this patient at elevated perioperative risk, especially in the setting of a prior sternotomy. One systematic review …”
- 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 Card Valve Repl denials overturned?
In 23 California IMR decisions from 2003 to 2023, reviewers overturned the plan 17 times (73.9%). In the last five years: 72.7% of 11.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.