Formulary v Non Form for CNS/ Neuromusc Dis: 64.3% of denials overturned
In 28 California IMR decisions from 2004 to 2011, reviewers overturned 18 (64.3%). 26 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 80.0% | 64.3% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 5 | 60.0% | 64.3% |
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 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 …”
“A 64-year-old female enrollee has requested Ambien for treatment of her insomnia. Findings: Two physician reviewers found that this patient’s insomnia has been treated ineffectively with Ambien (zolpidem). The records indicate that she was started on the medication a few years ago and steadily self-tapered to a maximum dose of 15 mg at night as she wasn’t having the desired …”
“A 67-year-old male enrollee has requested for Lunesta for treatment of his insomnia. Findings: The physician reviewer found that the medical studies do not support the contention that Lunesta is less safe and effective than benzodiazepines (which this patient has tried and failed) in the elderly patient population. It is true that all hypnotics can potentially cause undesirable side-effects (as …”
And one the reviewer upheld
“A 52-year-old female enrollee has requested for Amrix 15mg for treatment of her headaches, neck pain and muscle spasms. Findings: The physician reviewer found that this patient’s more severe headaches with nausea and vomiting most likely represent migraine. Triptans are within the standard of care in this setting if not medically contraindicated. Migraine preventive medications such as a tricyclic antidepressant …”
- 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 CNS/ Neuromusc Dis overturned?
In 28 California IMR decisions from 2004 to 2011, reviewers overturned 18 (64.3%). 26 were medical-necessity disputes, 2 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.