Formulary v Non Form denials: 39.6% overturned by independent reviewers
In 197 California IMR decisions from 2003 to 2011, reviewers overturned the plan 78 times (39.6%). 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 |
|---|---|---|---|
| CNS/ Neuromusc Dis | 28 | 64.3% | — |
| Digestive System/ GI | 27 | 18.5% | — |
| Orth/Musculoskeletal | 27 | 40.7% | — |
| Cardiac/Circ Problem | 26 | 23.1% | — |
| Mental Disorder | 24 | 62.5% | — |
| Endocrine/Metabolic | 14 | 28.6% | — |
| Respiratory System | 13 | 46.2% | — |
| GU/ Kidney Disorder | 9 | 11.1% | — |
| Skin Disorders | 9 | 33.3% | — |
| Immuno Disorders | 6 | 16.7% | — |
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. | 23 | 56.5% | 39.6% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 22 | 31.8% | 39.6% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 20 | 15.0% | 39.6% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 16 | 50.0% | 39.6% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 16 | 0.0% | 39.6% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 9 | 22.2% | 39.6% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 50.0% | 39.6% |
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 59-year-old female enrollee has requested Lipitor 20 mg for treatment of her hyperlipidemia. Findings: The physician reviewer found that with reference to the current medical literature regarding the use of statins in patients without known or symptomatic heart disease for primary prevention, Lipitor has been extensively studied in the primary and secondary prevention of cardiovascular events. In addition, some …”
“The parent of a 10-year-old female enrollee has requested Vyvanse 20 mg for treatment of the enrollee’s attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that Vyvanse is the only ADHD medication that includes data on abuse liability. The fact that extensive data is available for Vyvanse and other longer acting medication makes this group of medication a …”
“A 61-year-old male enrollee has requested Ambien CR 12.5 mg for treatment of his sleep disorder. Findings: The physician reviewer found that this patient has sleep difficulties with intolerance to CPAP. The records indicate that he has been treated with Ambien in the past and developed a tolerance to that medication. This patient’s sleep history is not detailed in the …”
- 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 Formulary v Non Form denials overturned?
In 197 California IMR decisions from 2003 to 2011, reviewers overturned the plan 78 times (39.6%).
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.