Dental Anesthesia for Autism Spectrum: 83.3% of denials overturned
In 6 California IMR decisions from 2016 to 2019, reviewers overturned 5 (83.3%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia services during dental work to be performed in a hospital or surgical setting. The Health Plan has denied this request indicating that the requested services are not medically necessary for management of the enrollee’s dental condition. Findings: The submitted documentation supports the medical necessity for …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dental anesthesia for treatment of the enrollee’s dental treatment. Findings: The physician reviewer found that the request for dental anesthesia service is medically necessary for treatment of the patient’s medical condition. In general, intravenous sedation or general anesthesia is indicated for patients with acute situational anxiety due …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dental surgery and anesthesia procedure for treatment of the enrollee’s dental caries and chronic periodontitis. Findings: The physician reviewer found that “Patients with special needs often present a challenge for the dental care team. The exacting and surgical nature of dental procedures requires significant patient cooperation to …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: Dental anesthesia may be indicated for patients with documentation of a failed attempt at local anesthesia and light sedation, when treatment is not feasible based on the medical needs of the patient, or if the patient requires extensive treatment that cannot be rendered under local anesthesia. While dental anesthesia has been shown to be safe …”
- 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 Dental Anesthesia denials for Autism Spectrum overturned?
In 6 California IMR decisions from 2016 to 2019, reviewers overturned 5 (83.3%). 6 were medical-necessity disputes.
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.