Clin Trial (I) for Cancer: 27.8% of denials overturned
In 18 California IMR decisions from 2001 to 2016, reviewers overturned 5 (27.8%). 3 were medical-necessity disputes, 15 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. | 11 | 18.2% | 27.8% |
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: An enrollee has requested participation in a clinical trial for treatment of his medical condition. Findings: Two physician reviewers found that often there is no better therapy to offer a patient than enrollment onto a well-designed, scientifically valid, peer-reviewed clinical trial. According to the National Comprehensive Cancer Network (NCCN) guidelines the best management of any …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication combination Yervoy (ipilimumab) 300 mg and Opdivo (nivolumab) 92 mg, for three weeks, refills for one year, nine cycles for treatment of the enrollee’s medical condition. Findings: Two physician reviewers found that Opdivo, Yervoy, and Keytruda are new monoclonal antibodies that bind with tumor antigens responsible for blocking immune …”
“A 60-year-old male enrollee has requested for Nexavar, administered as part of Protocol 06-03 for treatment of his metastatic melanoma. Findings: Two physician reviewers found that the clinical trial offered to this patient is well-designed and offers him chance of benefit. Bevacizumab is active in a wide variety of cancers and is promising in melanoma given the high levels of …”
And one the reviewer upheld
“A 64-year-old female enrollee has requested for a Phase I clinical trial of Avastin and valproic acid for treatment her colorectal cancer. Findings: The physician reviewer found that avastin has been approved for use when combined with chemotherapy in the treatment of metastatic colon cancer. However, there is no convincing data that Avastin is efficacious when used later in the …”
- 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 Clin Trial (I) denials for Cancer overturned?
In 18 California IMR decisions from 2001 to 2016, reviewers overturned 5 (27.8%). 3 were medical-necessity disputes, 15 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.