Genetic/Genomic Test for Immuno Disorders: 33.3% of denials overturned
In 6 California IMR decisions from 2018 to 2023, reviewers overturned 2 (33.3%). In the last five years: 33.3% of 3. , 6 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 2 | 50.0% |
| 2023 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for nerve testing. The autonomic nervous system regulates certain body processes including a patient’s blood pressure and rate of breathing. Disorders of the autonomic nervous system can affect any body part or process and can reversible or progressive. Establishing a diagnosis is helpful in determining appropriate further care. Autonomic testing …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for XomeDx (whole exome sequencing) Trio – GeneDx. Findings: Two of the three physician reviewers found whole exome sequencing is a technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patient’s phenotype. Whole exome sequencing may …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing services [F5 (coagulation factor V) (e.g. hereditary hypercoagulability) gene analysis, Leiden variant; F2 (prothrombin, coagulation factor II) (e.g. hereditary hypercoagulability) gene analysis, 20210G>A variant; and MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g. hereditary hypercoagulability) gene analysis, common variants (e.g. 677T, 1298C)]. There is a lack of evidence to support the …”
- 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 Genetic/Genomic Test denials for Immuno Disorders overturned?
In 6 California IMR decisions from 2018 to 2023, reviewers overturned 2 (33.3%). In the last five years: 33.3% of 3. , 6 experimental/investigational.
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.