Formulary v Non Form for Skin Disorders: 33.3% of denials overturned
In 9 California IMR decisions from 2004 to 2010, reviewers overturned 3 (33.3%). 9 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 4 | 25.0% | 33.3% |
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 patient is a 58-year-old female who has had rosacea for many years. Her previous provider indicates she had much greater improvement with Finacea gel than with MetroGel or Doxycycline. The patient’s request for authorization of Finacea gel was denied based upon the Health Plan’s determination that it was not medically necessary to treat her rosacea.The patient’s rosacea has been …”
“The patient is a 40-year-old male with psoriasis, which has become progressively more extensive. Ultraviolet light treatment resulted in significant pain. Soriatane was ineffective and was discontinued due to elevated liver enzymes. The patient’s liver enzymes remain elevated. The patient’s dermatologist and primary care physician have recommended treatment with Enbrel injections. The Health Plan has denied coverage for Enbrel on …”
“The patient is a 35-year-old man who has been prescribed Elidel to treat intertriginous dermatitis of the groin. The patient’s provider is concerned that treatment with steroids could cause atrophy and permanent damage. The Health Plan has denied authorization and coverage for Elidel on the basis that it is not medically necessary.Elidel is an effective treatment for many skin conditions …”
And one the reviewer upheld
“A 37-year-old female enrollee has requested Duac CS for treatment of her acne. Findings: The physician reviewer found that the prescription ingredient in Duac is a combination of benzoyl peroxide 5% and clindamycin 1% in a gel. The Duac CS kit also contains a face wash that is available over-the-counter. The formulary medication BenzaClin also contains benzoyl peroxide 5% and …”
- 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 Skin Disorders overturned?
In 9 California IMR decisions from 2004 to 2010, reviewers overturned 3 (33.3%). 9 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.