Formulary v Non Form for Cardiac/Circ Problem: 23.1% of denials overturned
In 26 California IMR decisions from 2004 to 2011, reviewers overturned 6 (23.1%). 26 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 0.0% | 23.1% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 25.0% | 23.1% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 3 | 0.0% | 23.1% |
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 …”
“A 64-year-old male enrollee has requested Zetia 10mg for the treatment of his high cholesterol. Findings: The physician reviewer found that the patient has been taking Crestor at the maximum dose. This dose of Crestor is stronger than or equivalent to Lipitor 80mg or simvastatin 80mg per day (formulary alternatives). There is no medical advantage to requiring that the patient …”
“A 59-year-old male enrollee has requested Lipitor for the treatment of his coronary artery disease. Findings: The physician reviewer found that this particular patient has been on Lipitor for two years with efficacious control of his hyperlipidemia. Lipitor was previously authorized by the Health Plan for treatment of this condition. It would not be medically appropriate to require the patient …”
And one the reviewer upheld
“A 59-year-old male enrollee has requested Crestor 20mg for treatment of his hyperlipidemia and peripheral vascular disease. Findings: The physician reviewer found that in this circumstance, medical therapy for treatment of hyperlipidemia with an HMG-CoA reductase inhibitor is reasonable, appropriate, and considered standard accepted practice in the medical community. However, this patient has not had a trial of higher dose …”
- 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 for Cardiac/Circ Problem overturned?
In 26 California IMR decisions from 2004 to 2011, reviewers overturned 6 (23.1%). 26 were medical-necessity disputes.
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.