Formulary v Non Form for Orth/Musculoskeletal: 40.7% of denials overturned
In 27 California IMR decisions from 2003 to 2010, reviewers overturned 11 (40.7%). 27 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 66.7% | 40.7% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 0.0% | 40.7% |
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 48-year-old female enrollee has requested Qualaquin for treatment of her polyneuropathy. Findings: The physician reviewer found that this patient has a familial sensorimotor polyneuropathy, and this is commonly associated with muscle cramping. This patient has used Qualaquin for her cramping with good results for many years. Qualaquin is effective for the treatment of cramping in some patients. She had …”
“A 63-year-old female enrollee has requested Boniva (150mg once per month) for the treatment of her osteoporosis. Findings: The physician reviewer found that it is not medically appropriate to require this patient to use weekly Fosamax as a prerequisite to taking monthly Boniva since she had been on Actonel weekly and demonstrated GERD symptoms. The use of Actonel 75 mg …”
“A 55-year-old female enrollee has requested for the prescription medication Lyrica for treatment of her lumbosacral radiculitis. Findings: The physician reviewer found that the FDA approved indications for Lyrica are limited, it is commonly prescribed for neuropathic pain when more conservative treatment strategies have proven to be ineffective, as in this case.”
And one the reviewer upheld
“A 29-year-old female enrollee has requested Celebrex for treatment of her temporomandibular joint disorder (TMJ). Findings: The physician reviewer found that Celebrex is not medically necessary for the treatment of the patient’s condition. There is no documentation in the patient’s medical records that there was treatment failure with a second non-steroidal anti-inflammatory drug (NSAID) in order to qualify for treatment …”
- 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 Orth/Musculoskeletal overturned?
In 27 California IMR decisions from 2003 to 2010, reviewers overturned 11 (40.7%). 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.