Extracorp Shock Wave denials: 19.5% overturned by independent reviewers
In 41 California IMR decisions from 2005 to 2019, reviewers overturned the plan 8 times (19.5%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Foot Disorder | 36 | 22.2% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 22 | 27.3% | 19.5% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 17 | 23.5% | 19.5% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 12 | 25.0% | 19.5% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 9 | 0.0% | 19.5% |
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: An enrollee has requested reimbursement for high intensity shockwave therapy for treatment of the enrollee’s plantar fasciitis. Findings: The physician reviewers found that the therapy at issue was likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. There is high quality peer-reviewed evidence to support the safety …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested extracorporeal shock wave therapy for the treatment of her medical condition. Findings: Two physician reviewers found that the medical evidence supports the requested services in this clinical setting. This patient has Kohler’s disease which is a condition affecting the vascularity to the navicular bones that has the potential of altering the …”
“A 38-year-old male enrollee has requested for extracorporeal shock wave therapy for treatment of his plantar fasciitis. Findings: Two physician reviewers found that there is adequate outcome data to support the use of ESWT for the treatment of plantar fasciitis that has failed to respond to conservative treatment. ESWT is performed more commonly for plantar fasciitis than open surgical treatment …”
- 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 Extracorp Shock Wave denials overturned?
In 41 California IMR decisions from 2005 to 2019, reviewers overturned the plan 8 times (19.5%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.