Early Discharge for Cancer: 33.3% of denials overturned
In 6 California IMR decisions from 2009 to 2023, reviewers overturned 2 (33.3%). In the last five years: 50.0% of 2. 6 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2023 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospital services.Based upon the submitted documentation, the inpatient hospital services at issue were medically necessary to treat the patient’s medical condition. The patient presented with a large right lung cancer requiring major chest surgery with the removal of the entire right lung. Like …”
“A 64-year-old female enrollee has requested continued acute care stay for the treatment of her stage IV right breast carcinoma, metastatic to the bone. Findings: The physician reviewer found that the patient underwent L3 to L5 laminectomy, resection of L4 inferior and partial superior facet joint, resection of pedicle tumor, dissection of lateral mass transverse process tumor right-sided, resection of …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for hospitalization services from 4/4/21 forward. The records document that this patient has glioblastoma multiforme. By 4/6/21, the patient has been medically stable, and she has not required advanced interventions or monitoring. She experienced chronic lactic acidosis and tachycardia that has been managed with a …”
- 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 Early Discharge denials for Cancer overturned?
In 6 California IMR decisions from 2009 to 2023, reviewers overturned 2 (33.3%). In the last five years: 50.0% of 2. 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.