Formulary v Non Form for Respiratory System: 46.2% of denials overturned
In 13 California IMR decisions from 2004 to 2011, reviewers overturned 6 (46.2%). 13 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“A 44-year-old female enrollee has requested for the medication Zyrtec (not the generic version) for treatment of her allergies. Findings: The physician reviewer found that generic products can sometimes have intrasubject variability. Thus, for some patients, the generic equivalent may not be as effective as the brand version. In this patient’s case, she has allergy symptoms that were not relieved …”
“The patient is a 61-year-old female with reactive airway disease, IgE mediated rhinitis, chronic sinusitis and seasonal and perennial allergies related to mite, mold and animal dander. She has moderate to severe asthma which is steroid dependent and her condition is deteriorating. The patient also has an evolving depression that is situational, secondary to her chronic allergic disease and its …”
“The patient is a 28-year-old male with severe asthma. He previously participated in a clinical trial of Xolair, which was very effective in controlling his asthma and his FEV1 increased from 41% to 84%. Since Xolair was discontinued his pulmonary function tests have declined significantly, despite maximal therapy. The patient’s IgE was 301 in October 2005 and he has tested …”
And one the reviewer upheld
“The parent of a 14-year-old male enrollee has requested a Xopenex inhaler for treatment of the enrollee’s asthma. Findings: The physician reviewer found that levalbuterol, the R-isomeric form of albuterol, was developed to increase the efficacy of bronchodilation while decreasing side effects such as tachycardia and loss of potency. However, in head-to-head studies, levalbuterol has not consistently been shown to …”
- 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 Respiratory System overturned?
In 13 California IMR decisions from 2004 to 2011, reviewers overturned 6 (46.2%). 13 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.