Emergency Room for Vision: 45.5% of denials overturned
In 11 California IMR decisions from 2008 to 2019, reviewers overturned 5 (45.5%). , 11 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 11 | 45.5% | 45.5% |
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 experienced sudden vision loss symptoms of the left eye. The patient was diagnosed with retinal detachment and macular pucker in the left eye. He underwent repair of retina detachment, pars plana vitrectomy, membrane peeling, air fluid exchange and gas to the left eye. At issue, is whether the retina surgery that was …”
“Nature of Statutory Criteria/Case Summary: An enrollee requested services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that the patient’s decision to seek immediate medical attention was consistent with the actions of a prudent layperson. Upon review of the submitted medical records, the patient presented with soft tissue swelling, redness and …”
“A 58 year old female has requested emergency room services for treatment of her recurrent retinal detachment. Findings: The physician reviewer found that a prudent layperson in this situation would have sought immediate medical attention. Proliferative vitreoretinopathy (PVR) is a condition that develops as a complication of retinal detachment due to a break in the retina, or rhegmatogenous retinal detachment. …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A 28-year-old male enrollee has requested reimbursement for ophthalmology services provided on the basis the services were emergent in nature. Findings: The physician reviewer found that a central retinal vein occlusion whether ischemic or non-ischemic is not a medical emergency that requires emergent treatment (Hahn, et al. and Ho, et al.) While it is a …”
- 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 Vision overturned?
In 11 California IMR decisions from 2008 to 2019, reviewers overturned 5 (45.5%). , 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.