Formulary v Non Form for Mental Disorder: 62.5% of denials overturned
In 24 California IMR decisions from 2003 to 2011, reviewers overturned 15 (62.5%). 24 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. | 5 | 80.0% | 62.5% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 66.7% | 62.5% |
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
“The parent of a 10-year-old female enrollee has requested Vyvanse 20 mg for treatment of the enrollee’s attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that Vyvanse is the only ADHD medication that includes data on abuse liability. The fact that extensive data is available for Vyvanse and other longer acting medication makes this group of medication a …”
“A 21-year-old male enrollee has requested Subutex, 8 mg (30 tablets per month) for treatment of his opioid dependence in remission. Findings: The physician reviewer found that a review of the literature shows that buprenorphine-naloxone (Suboxone) and buprenorphine (Subutex) are effective in the treatment of patients with opioid substance addictions. “Based on the available literature, it appears that buprenorphine, buprenorphine-naloxone, …”
“A 39-year-old male enrollee has requested Lexapro 10mg for treatment of his major depression. Findings: The physician reviewer found that per the patient and the treating physician, Celexa lost its effectiveness after several years. He was subsequently switched to Lexapro 10mg per day. This is working well, per the treating physician. Montgomery and colleagues noted the statistically significant superiority of …”
And one the reviewer upheld
“A 50-year-old female enrollee has requested Adderall, 150mg per day for treatment of her attention deficit disorder. Findings: The physician reviewer found that side effects of stimulants are dose-dependent and include increased blood pressure. Side effects can often be managed by lowering the dose. Rostain also notes that attention deficit/hyperactivity disorder medications may increase blood pressure and heart rate in …”
- 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 Mental Disorder overturned?
In 24 California IMR decisions from 2003 to 2011, reviewers overturned 15 (62.5%). 24 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.