Card Valve Repl for Cardiac/Circ Problem: 73.9% of denials overturned
In 23 California IMR decisions from 2003 to 2023, reviewers overturned 17 (73.9%). In the last five years: 72.7% of 11. 13 were medical-necessity disputes, 10 experimental/investigational.
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 …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter aortic valve replacement (TAVR) procedure. Findings: The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved TAVR for the treatment of patients with symptomatic severe aortic valve stenosis. However, the guidelines from the American College of Cardiology (ACC) and American Heart Association …”
- 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 for Cardiac/Circ Problem overturned?
In 23 California IMR decisions from 2003 to 2023, reviewers overturned 17 (73.9%). In the last five years: 72.7% of 11. 13 were medical-necessity disputes, 10 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.