Formulary v Non Form for Digestive System/ GI: 18.5% of denials overturned
In 27 California IMR decisions from 2004 to 2011, reviewers overturned 5 (18.5%). 27 were medical-necessity disputes.
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. | 3 | 66.7% | 18.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 18.5% |
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 50-year-old female enrollee has requested Dexilant/Kapidex for treatment of her gastroesophageal reflux disease. Findings: The physician reviewer found that given that this patient has failed treatment with several medications and at varied dosages, Dexilant/Kapidex is an appropriate next step for treatment of her reflux. In this patient’s case, Dexilant/Kapidex is medically indicated.”
“A 59-year-old female enrollee has requested for the medication Aciphex for treatment of her gastroesophageal reflux disorder (GERD). Findings: The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, and they continue to be the standard of therapy for the treatment of gastroesophageal reflux disease. All PPIs decrease acid secretion by …”
“A 64-year-old female enrollee has requested the prescription medication Lialda for the treatment of her ulcerative colitis. Findings: The physician reviewer found that mesalamines are a class of drug that act topically on the colonic mucosa to reduce inflammation. They are considered first-line therapy for active, mild-to-moderate ulcerative colitis. Lialda is a recently approved, high-strength, oral formulation mesalamine with a …”
And one the reviewer upheld
“A 29-year-old female enrollee has requested Xifaxan for treatment of her Crohn’s disease and small intestinal bacterial overgrowth (SIBO). Findings: The physician reviewer found that the record indicates that the enrollee has been diagnosed with Crohn’s disease and SIBO. The long term use of Xifaxan is not FDA approved for the treatment of either of these conditions. Additionally, the patient …”
- 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 Digestive System/ GI overturned?
In 27 California IMR decisions from 2004 to 2011, reviewers overturned 5 (18.5%). 27 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.