Formulary v Non Form for Endocrine/Metabolic: 28.6% of denials overturned
In 14 California IMR decisions from 2004 to 2011, reviewers overturned 4 (28.6%). 14 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 0.0% | 28.6% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 3 | 0.0% | 28.6% |
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 51-year-old female enrollee has requested the prescription drug Starlix for the treatment of her diabetes. Findings: The physician reviewer found that this patient has diabetes, which was diet-controlled until recently. Progression of diabetes is consistent with elevated postprandial glucose levels and loss of early postprandial insulin response. The patient developed hypoglycemia with sulfonylurea. A glinide is a good choice …”
“A fifty-six year-old male with diabetes type II and cardiac and renal complications is requesting reimbursement, authorization, and coverage for continuation of treatment with Byetta. The patient was not optimally controlled on three oral agents and a very small dose of bedtime NPH insulin.Reviewer’s Findings:The reviewing physician found that Byetta is presently indicated as adjunctive therapy to improve glycemic control …”
“The patient is a 54-year-old female diagnosed with type 2 diabetes mellitus (DM2). She had been under poor control despite four oral hypoglycemic agents. Her hemoglobin A1c was 7.9% in February 2006. The patient’s endocrinologist began a trial of Byetta 5mcg twice a day in March 2006. The provider stated that after one month the patient’s self-monitored blood glucose levels …”
And one the reviewer upheld
“A 39-year-old female enrollee has requested SymlinPen for treatment of her diabetes mellitus. Findings: The physician reviewer found that in this patient’s case, the submitted documentation fails to establish the medical necessity of the requested SymlinPen. Symlin is indicated when hemoglobin A1C is less than or equal to 9 to help optimize blood glucose control. This patient’s hemoglobin A1C was …”
- 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 Endocrine/Metabolic overturned?
In 14 California IMR decisions from 2004 to 2011, reviewers overturned 4 (28.6%). 14 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.