Emergency Room for Infectious Disease: 63.6% of denials overturned
In 11 California IMR decisions from 2008 to 2018, reviewers overturned 7 (63.6%). , 11 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 11 | 63.6% | 63.6% |
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 he had received. Findings: The physician reviewer found that the patient who presented reports that his sexual partner had gonorrhea. Physical examination revealed a lesion at the base of the penis. He underwent testing for gonorrhea and chlamydia. He was advised to undergo laboratory testing. The …”
“A 36-year-old male enrollee requested post-exposure prophylaxis (PEP) on an emergent basis for medical treatment of his possible HIV exposure. Findings: The physician reviewer found that it is recommended that patients with a known exposure to HIV receive PEP as soon as possible, up to 72 hours post exposure. PEP is a time-sensitive treatment and should be administered as soon …”
“A 45-year-old male enrollee has requested emergency services for treatment of his peri-rectal abscess. Findings: The physician reviewer found that the disputed services meet prudent layperson criteria for emergency care given the totality of the patient’s circumstances. The patient had a large peri-rectal abscess which was incised, drained of copious pus, and packed with gauze on the first visit to …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings: The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, there was no emergent medical condition noted in …”
- 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 Infectious Disease overturned?
In 11 California IMR decisions from 2008 to 2018, reviewers overturned 7 (63.6%). , 11 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.