Cataract Surgery denials: 45.0% overturned by independent reviewers
In 20 California IMR decisions from 2003 to 2022, reviewers overturned the plan 9 times (45.0%). In the last five years: 100.0% of 2. 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 |
|---|---|---|---|
| Vision | 19 | 47.4% | 100.0% of 2 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 2 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 40.0% | 45.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 0.0% | 45.0% |
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
“The physician reviewer found that The patient has requested authorization and coverage for left eye cataract surgery with monofocal lens replacement. In this case, the patient’s visual acuity is noted as 20/25, with trace changes in the lens. However, testing results show mild reduction of contrast sensitivity in the left eye and reduced visual acuity on brightness acuity testing. Overall, …”
“The physician reviewer found that An enrollee has requested authorization and coverage for iStent Trabecular Micro-Bypass Stent. The patient demonstrates the findings typically seen in patients with early glaucoma. The provider noted that the patient has shown some issues with medication compliance. The provider has recommended intervention with the iStent procedure. On review of the current peer-reviewed medical literature, there …”
“Nature of Statutory Criteria/Case Summary: The spouse of an enrollee has requested authorization and coverage for immediate cataract surgery.The American Academy of Ophthalmology (AAO) has issued interim guidelines on resuming elective ophthalmic care during the COVID-19 pandemic. The AAO states that cataract surgery is considered semi-urgent, not elective, when the affected person cannot drive, work or see to take their …”
- 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 Cataract Surgery denials overturned?
In 20 California IMR decisions from 2003 to 2022, reviewers overturned the plan 9 times (45.0%). In the last five years: 100.0% of 2.
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.