Chemotherapy for Cancer: 40.9% of denials overturned
In 252 California IMR decisions from 2002 to 2021, reviewers overturned 103 (40.9%). In the last five years: 23.1% of 13. 103 were medical-necessity disputes, 149 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 13 | 23.1% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 71 | 32.4% | 40.9% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 36 | 30.6% | 40.9% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 29 | 37.9% | 40.9% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 25 | 32.0% | 40.9% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 17 | 41.2% | 40.9% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 11 | 45.5% | 40.9% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 9 | 11.1% | 40.9% |
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 reimbursement for radiation therapy services. Findings: The physician reviewer found that atient is noted to have moderately differentiated estrogen receptor (ER) positive, progesterone receptor (PR) positive, invasive ductal carcinoma with micropapillary features. She underwent treatment with surgery and intraoperative radiation therapy (IORT). The records provided for review support that this patient …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tbo-filgrastim (Granix), 1 microgram injections (J1447). Findings: The physician reviewer found that white blood count growth factors are supported to reduce a patient’s risk of neutropenic fever when the anticipated risk of neutropenic fever for a chemotherapy regimen is approximately 20% (Smith, et al.). This patient’s records …”
“Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for Inlyta (axitinib). While there is a lack of evidence from strict randomized clinical trial evidence due to the rarity of soft tissue sarcomas, phase 2 clinical trials have shown promise regarding the use of axitinib and pembrolizumab. Wilky and colleagues report in single-center, single-arm, phase 2 …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Opdivo (nivolumab) 240 mg every two weeks.Nivolumab is not approved by the U.S. Food and Drug Administration (FDA) for the treatment of oligodendrogliomas. Moreover, nivolumab use for oligodendrogliomas is not supported by major drug compendia. Alternatively, pembrolizumab is approved by the FDA for tumor mutational burden-high tumors. …”
- 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 Chemotherapy denials for Cancer overturned?
In 252 California IMR decisions from 2002 to 2021, reviewers overturned 103 (40.9%). In the last five years: 23.1% of 13. 103 were medical-necessity disputes, 149 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.