Hormones for OB-GYN/ Pregnancy: 17.5% of denials overturned
In 57 California IMR decisions from 2001 to 2018, reviewers overturned 10 (17.5%). 34 were medical-necessity disputes, 23 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. | 18 | 5.6% | 17.5% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 8 | 12.5% | 17.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 0.0% | 17.5% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 4 | 0.0% | 17.5% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 4 | 0.0% | 17.5% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 33.3% | 17.5% |
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 authorization and coverage for the medication Premarin (hormone replacement therapy). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s post-menopausal symptoms. At issue in this case is whether the requested medication Premarin (hormone replacement therapy) is medically necessary for …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prometrium. The Health Plan has denied this request indicating that the requested name brand medication is not medically necessary for treatment of the enrollee who has a history of menopausal syndrome and fibromyalgia syndrome. Findings: The enrollee and the enrollee's provider state that HRT is appropriate to …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duavee 0.45 mg/20 mg tablets. Findings: The physician reviewer found that the request for Duavee 0.45 mg/20 mg tablets is medically necessary for treatment of the patient’s medical condition. Estrogen only regimens such as estradiol tablets and Estring are not medically appropriate in this clinical setting. In …”
And one the reviewer upheld
“The physician reviewer found that an enrollee has requested authorization and coverage for Femring 0.1 mg. Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. Vaginal atrophy causes bothersome vaginal symptoms commonly associated with menopause including vaginal or vulvar dryness, discharge, itching and dyspareunia. Local vaginal estradiol and local conjugated equine estrogen, which can be …”
- 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 OB-GYN/ Pregnancy overturned?
In 57 California IMR decisions from 2001 to 2018, reviewers overturned 10 (17.5%). 34 were medical-necessity disputes, 23 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.