Fibroid Removal for GU/ Kidney Disorder: 71.4% of denials overturned
In 7 California IMR decisions from 2019 to 2022, reviewers overturned 5 (71.4%). In the last five years: 100.0% of 2. 3 were medical-necessity disputes, 4 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 2 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 66.7% | 71.4% |
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 authorization and coverage for surgical removal of fibroids (laparoscopic myomectomy). The records document that this patient has a history of heavy bleeding and pelvic pain in the setting of a fibroid uterus. The patient has requested treatment with a uterine sparing procedure. On review of the peer-reviewed medical literature and current …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic surgical radiofrequency ablation (RFA) of uterine fibroids. Uterine fibroids are the most common benign tumors of the female reproductive tract causing symptoms such as heavy bleeding, bulk symptoms, pain, and increased urinary frequency. Some patients prefer minimally invasive approaches for fibroid treatment with desire for uterine …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hysteroscopy myomectomy procedure under a tertiary level of care. Vilos and colleagues note that for symptomatic fibroids causing menstrual abnormalities such as heavy, irregular, and prolonged uterine bleeding, hysterectomy is a definitive solution. The authors further stated that hysteroscopic myomectomy should be considered first-line conservative surgical …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acessa laparoscopic radiofrequency ablation procedure. Researchers concluded that, “laparoscopic radiofrequency ablation therapy is efficacious for small-sized and non-pedunculated symptomatic uterine fibroids.” Based on this review, this patient is not a suitable candidate for the Acessa laparoscopic radiofrequency ablation procedure. The patient’s fibroid is pedunculated and measures 6.9 …”
- 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 Fibroid Removal denials for GU/ Kidney Disorder overturned?
In 7 California IMR decisions from 2019 to 2022, reviewers overturned 5 (71.4%). In the last five years: 100.0% of 2. 3 were medical-necessity disputes, 4 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.