Fibroid Removal for OB-GYN/ Pregnancy: 42.9% of denials overturned
In 14 California IMR decisions from 2002 to 2017, reviewers overturned 6 (42.9%). 9 were medical-necessity disputes, 4 experimental/investigational, 1 urgent care.
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 | 0.0% | 42.9% |
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
“A 45-year-old female enrollee requested medical services on an emergent or urgently needed basis. Findings: The physician reviewer found that the patient presented with complaints of severe abdominal pain. Based on the documentation submitted for review, a prudent layperson would have sought medical care due to the severe abdominal pain such that the absence of immediate medical attention could reasonably …”
“A 46-year-old female enrollee has requested for a hysteroscopic myomectomy with simultaneous laparoscopic myomectomies for treatment of her uterine fibroids. Findings: The physician reviewer found that the advantages of laparoscopic myomectomy over abdominal myomectomy include less post-operative pain and recovery period, shorter hospitalization, and cosmetically smaller abdominal scars. Also reported are fewer post-operative adhesions peripheral to the site of surgery. …”
“A 46-year-old female enrollee has requested a laparoscopic myomectomy for the treatment of her uterine fibroid. Findings: The physician reviewer found that the laparoscopic approach for myomectomy is a medically appropriate option for this patient. The American College of Obstetrics and Gynecology (ACOG) notes that myomectomy may be an option for women who desire uterine preservation, and reports that laparoscopic …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for Acessa ablation minimally invasive procedure. Findings: The physician reviewer found that surgical options for uterine preservation in the treatment of fibroids include myomectomy, uterine artery embolization, magnetic resonance imaging (MRI) guided focused ultrasound surgery and radiofrequency ablation. The Acessa procedure uses radiofrequency ablation, which targets the fibroids, with …”
- 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 OB-GYN/ Pregnancy overturned?
In 14 California IMR decisions from 2002 to 2017, reviewers overturned 6 (42.9%). 9 were medical-necessity disputes, 4 experimental/investigational, 1 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.