Extracorp Shock Wave for Foot Disorder: 22.2% of denials overturned
In 36 California IMR decisions from 2005 to 2016, reviewers overturned 8 (22.2%). 7 were medical-necessity disputes, 29 experimental/investigational.
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. | 20 | 30.0% | 22.2% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 15 | 26.7% | 22.2% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 10 | 30.0% | 22.2% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 8 | 0.0% | 22.2% |
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 …”
And one the reviewer upheld
“A 46-year-old female enrollee requested extracorporeal shockwave therapy for medical treatment of her plantar fasciitis and Achilles tendonitis. Findings: Two physician reviewers found that in the peer-reviewed medical literature on the use of extracorporeal shockwave therapy for the treatment of chronic heel pain, there is a paucity of scientific data demonstrating improved health outcomes when compared to standard therapies. Many …”
- 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 for Foot Disorder overturned?
In 36 California IMR decisions from 2005 to 2016, reviewers overturned 8 (22.2%). 7 were medical-necessity disputes, 29 experimental/investigational.
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.