Hormones for Cancer: 60.0% of denials overturned
In 5 California IMR decisions from 2003 to 2019, reviewers overturned 3 (60.0%). 3 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
From recent overturned decisions
“An enrollee has requested reimbursement and prospective authorization and coverage for Sipuleucel-T (Provenge). Based on the available medical documentation, this patient has castrate resistant prostate cancer with lymph node metastasis. The records report a rising prostate specific antigen (PSA) with a testosterone of less than 20 ng/dL. As such, use of Provenge is clinically appropriate and generally accepted standard of …”
“A 62-year-old male enrollee has requested coverage for growth hormone (GH) therapy for treatment of his non-Hodgkin’s lymphoma.Findings: Three physician reviewers found that the use of human growth hormone to increase the yield of stem cells in patients who have inadequate response to Neupogen or Leukine is investigational. However, there is one paper published in the journal Blood which documents …”
“A 28-year-old female enrollee requested authorization and coverage of the medication Lupron or Zoladex. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollee’s medical condition. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plan’s denial on the basis that the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for progesterone suppositories and two Insulin Potentiation Therapy (IPT) treatments. The National Comprehensive Cancer Network (NCCN) standard preferred therapy for advanced staged III and IV and unresectable uterine cancer is chemotherapy with Platinum/Taxane therapy. Upfront surgery is very often necessary to make the diagnosis. However, while the estrogen …”
- 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 Hormones denials for Cancer overturned?
In 5 California IMR decisions from 2003 to 2019, reviewers overturned 3 (60.0%). 3 were medical-necessity disputes, 2 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.