Elect Bone Stim for Cardiac/Circ Problem: 40.0% of denials overturned
In 5 California IMR decisions from 2011 to 2022, reviewers overturned 2 (40.0%). In the last five years: 100.0% of 1. , 5 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
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% | 40.0% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 SLSA functional electrical stimulator (FES). In this case, the patient has a diagnosis of locked-in state. Emphasizing the need for significant multidisciplinary rehabilitation, Researchers report that multimodal treatments that are frequent and sensory can provide significant improvement for patients with locked-in syndrome. The authors further note …”
“Nature of Statutory Criteria/Case Summary: An enrollee requested the transcutaneous electrical nerve stimulation (TENS) supply two leads per month and the functional electrical stimulator for treatment of his embolic stroke. Findings: Two physician reviewers found that compared with standard therapy including continued use of an ankle foot orthoses, the Bioness L300 FES is likely to provide this patient with more …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The enrollee is a male who has requested authorization and coverage for a WalkAide System, Bioness L300. The Health Plan has denied the requested device as investigational for treatment of the enrollee’s foot drop.Findings: Three physician reviewers found that Current data suggest that ankle foot orthoses (AFO) have equally positive combined-orthotic effects as functional electrical …”
- 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 Elect Bone Stim denials for Cardiac/Circ Problem overturned?
In 5 California IMR decisions from 2011 to 2022, reviewers overturned 2 (40.0%). In the last five years: 100.0% of 1. , 5 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.