Colonoscopy/Sigmoid for Cancer: 25.0% of denials overturned
In 8 California IMR decisions from 2006 to 2020, reviewers overturned 2 (25.0%). 7 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 33.3% | 25.0% |
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
“A 36-year-old male has requested coverage for a past colonoscopy and prospective coverage for annual colonoscopies due to his personal history of colorectal cancer. Findings: The physician reviewer found that for patients with rectal or colon cancer, a colonoscopy is recommended within a few months after resection. In this patient’s case, he underwent resection and had a follow-up colonoscopy five …”
“A 55-year-old female enrollee has requested a repeat colonoscopy for an evaluation of her risk for colon cancer. Findings: The physician reviewer found that this patient is recommended to have a repeat colonoscopy every five years since she falls in the high-risk category based on her family history and personal history of cancer. Winawer and colleagues’ guidelines suggest that patients …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a colonoscopy. Findings: The physician reviewer found that United States Preventive Services Task Force (USPSTF) recommendation for colorectal cancer screening states, “The USPSTF did not specifically review the evidence on screening in populations at increased risk; however, other professional organizations recommend that patients with a family history …”
- 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 Colonoscopy/Sigmoid denials for Cancer overturned?
In 8 California IMR decisions from 2006 to 2020, reviewers overturned 2 (25.0%). 7 were medical-necessity disputes, 1 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.