Charite for Orth/Musculoskeletal: 0.0% of denials overturned
In 21 California IMR decisions from 2005 to 2005, reviewers overturned 0 (0.0%). , 21 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 21 | 0.0% | 0.0% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 10 | 0.0% | 0.0% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 8 | 0.0% | 0.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 0.0% | 0.0% |
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.
And one the reviewer upheld
“Physician 1: The patient is a 38-year-old female with degenerative disc disease at L5-S1 attributed to lifting a heavy object. The patient’s provider believes the L5-S1 disc is responsible for her pain based upon a discogram performed in August 2005. The patient has been identified as a candidate for artificial disc replacement, but the Health Plan considers this procedure experimental …”
- 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 Charite denials for Orth/Musculoskeletal overturned?
In 21 California IMR decisions from 2005 to 2005, reviewers overturned 0 (0.0%). , 21 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.