Emergency Room for Cancer: 66.7% of denials overturned
In 6 California IMR decisions from 2007 to 2018, reviewers overturned 4 (66.7%). 1 were medical-necessity disputes, 5 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 6 | 66.7% | 66.7% |
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 reimbursement for emergency medical services. Findings: The physician reviewer found that The patient who presented to the emergency department after being notified of a positive blood culture. The patient received a call from the emergency department advising him to go to the hospital immediately. Of note, the patient was seen the …”
“A 60-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would believe he was experiencing an emergency medical condition. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms …”
“The representative of a now deceased female enrollee has requested reimbursement for medical services for treatment of the enrollee’s sudden hepatic failure, breast cancer with multiple metastases and electrolyte imbalance. Findings: The physician reviewer found that the patient was seeking possible alternative treatment, but she deteriorated quickly and received standard emergency care just prior to her death.”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A 63-year-old male has requested reimbursement for intensive care unit (ICU) services provided on the basis the services were emergent in nature. The patient’s post-operative MRI showed resection of a large mass, but with mild brain edema and slight shift of brain structures from right to left. This suggested that he was still at risk …”
- 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 Emergency Room denials for Cancer overturned?
In 6 California IMR decisions from 2007 to 2018, reviewers overturned 4 (66.7%). 1 were medical-necessity disputes, 5 urgent care.
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.