Emergency Room for Trauma/ Injuries: 54.5% of denials overturned
In 22 California IMR decisions from 2008 to 2022, reviewers overturned 12 (54.5%). In the last five years: 100.0% of 1. 3 were medical-necessity disputes, 19 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 21 | 57.1% | 54.5% |
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: The patient has requested reimbursement for services at Regional Medical Center of San Jose. The patient presented to the emergency department with two days of pain not controlled with pain medications and was anxious and in mild distress due to pain. Halawi and Morwood report that open fractures are complex injuries associated with high morbidity …”
“Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested reimbursement for emergency services including transportation. Findings: The physician reviewer found that according to the documentation submitted for review, the patient presented to the emergency department after an injury to the dorsum of her foot with a large piece of glass. She sustained significant continued blood loss following laceration …”
“Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for emergency medical services. Findings: The physician reviewer found that The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department with a dog bite the day prior. The dog had not been vaccinated for rabies. The patient …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for air ambulance services. A patient might require air ambulance services in order to be transferred from one institution to another in order to receive specialized services. In such a case, the patient must be transferred to the closest facility capable of providing the specialty services. Per …”
- 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 Trauma/ Injuries overturned?
In 22 California IMR decisions from 2008 to 2022, reviewers overturned 12 (54.5%). In the last five years: 100.0% of 1. 3 were medical-necessity disputes, 19 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.