Hormones for Infectious Disease: 50.0% of denials overturned
In 6 California IMR decisions from 2005 to 2015, reviewers overturned 3 (50.0%). 4 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
From recent overturned decisions
“A male enrollee requested for AndroGel for medical treatment his hypogonadism. Findings: The physician reviewer found that low testosterone can lead to complications such as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). This treatment should therefore help to prevent potential complications from untreated hypogonadism. All told, …”
“A 53-year-old male enrollee has requested growth hormone Serostim for treatment of his HIV related lipodystrophy. Findings: Two physician reviewers found that there are two randomized, controlled trials for the use of Serostim for (HARS). The results of these are included in the FDA approved package insert for Serostim and show significant improvement in visceral adipose tissue in patients treated …”
“The patient is an HIV-positive 48-year-old male under the care of an HIV care physician who has requested recombinant human growth hormone (rhGH) to treat severe fat redistribution syndrome of HIV (also referred to as visceral adipose tissue accumulation or lipodystrophy). The patient has visceral fat accumulation (lipohypertrophy) as well as facial and peripheral lipoatrophy and has experienced improvement on …”
And one the reviewer upheld
“A male enrollee requested Serostim 4 mg daily for medical treatment of his lipodystrophy secondary to human immunodeficiency virus (HIV) medications. Findings: The physician reviewer found that as noted by the U.S. Food and Drug Administration (FDA), Serostim is “indicated for the treatment of HIV patients with wasting or cachexia to increase lean body mass and body weight, and improve …”
- 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 Infectious Disease overturned?
In 6 California IMR decisions from 2005 to 2015, reviewers overturned 3 (50.0%). 4 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.