Formulary v Non Form for Immuno Disorders: 16.7% of denials overturned
In 6 California IMR decisions from 2006 to 2009, reviewers overturned 1 (16.7%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“A 42-year-old female enrollee has requested Lidoderm patches for the treatment of her chronic pain. Findings: The physician reviewer found that while there is no evidence of controlled trials of Lidoderm patches in the treatment of fibromyalgia, a study of pain relief in myofascial pain syndrome (a related chronic pain syndrome) showed significant improvement in pain control and somatic pain …”
And one the reviewer upheld
“A 51-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia. Findings: The physician reviewer found that the medical necessity of Lyrica 75mg daily is not established based on the records provided. While it is true that Lyrica is the first drug approved by the Food and Drug Administration for treatment of fibromyalgia, the other standard drugs used …”
- 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 Immuno Disorders overturned?
In 6 California IMR decisions from 2006 to 2009, reviewers overturned 1 (16.7%). 6 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.