Emergency Room for Pediatrics: 85.7% of denials overturned
In 7 California IMR decisions from 2008 to 2013, reviewers overturned 6 (85.7%). , 7 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 7 | 85.7% | 85.7% |
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
“The parent of a three-year-old male enrollee has requested emergency services for treatment of the enrollee's fever. Findings: The physician reviewer found that the submitted documentation demonstrates the patient’s symptoms met prudent layperson criteria for emergency care. The patient presented with acute symptoms of pain, lethargy and fever which were of sufficient severity such that the absence of immediate medical …”
“The parent of a then three-year-old female has requested coverage for past emergency services. Findings: The physician reviewer found that the patient was brought to the emergency department with complaints of cough and congestion for several days and acute onset of right ear pain one hour prior to arrival. Vital signs in the emergency department included temperature 99.2 degrees, respiratory …”
“A 20-year-old female enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating the services at issue were not required on an emergent basis. Findings: The physician reviewer found that The patient presented to the emergency department with chief complaint of sore throat of four days duration associated with cough, headache, runny nose, joint pain …”
And one the reviewer upheld
“The parent of a 4-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings: The physician reviewer found that the prudent layperson standard for an emergency requires that the patient’s condition be of acute onset and of such severity that a prudent layperson would believe his or her health to be in jeopardy without …”
- 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 Pediatrics overturned?
In 7 California IMR decisions from 2008 to 2013, reviewers overturned 6 (85.7%). , 7 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.