Genetic/Genomic Test for OB-GYN/ Pregnancy: 94.1% of denials overturned
In 17 California IMR decisions from 2018 to 2019, reviewers overturned 16 (94.1%). , 17 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 100.0% | 94.1% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal chromosomal aneuploidy (CPT 81420) genetic testing. The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin regarding non-invasive prenatal testing. The ACOG bulletin noted that “cell-free DNA screening evaluates short segments of DNA in maternal blood and can be used to screen for a …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the spinal muscular atrophy (SMA) carrier testing. Findings: Three physician reviewers found that recently, genetic carrier screening before and/or during pregnancy for certain genetic disorders has become an integral part of patient care. According to the American College of Obstetricians and Gynecologists (ACOG), screening for spinal muscular atrophy should …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing.Findings: Two of the three physician reviewers found that the American College of Obstetricians and Gynecologists recommends genetic screening for common recessive diseases in all populations. The genetic testing performed in this patient’s case has been validated. The genetic testing ordered included the diseases recommended by American College …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (fetal sex and/or fetal chromosomal microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in maternal blood).Findings: Two of the three physician reviewers found that the American College of Obstetricians and Gynecologists recommends cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. …”
- 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 OB-GYN/ Pregnancy overturned?
In 17 California IMR decisions from 2018 to 2019, reviewers overturned 16 (94.1%). , 17 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.