Hyperbaric O2 Chamb for Cancer: 62.5% of denials overturned
In 8 California IMR decisions from 2005 to 2024, reviewers overturned 5 (62.5%). In the last five years: 0.0% of 2. 5 were medical-necessity disputes, 3 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2024 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 66.7% | 62.5% |
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: The patient has requested authorization and coverage for hyperbaric oxygen chamber treatment and retrograde urethrogram. This patient has a history of prostate cancer and he presents with radiation cystitis. His clinical outcome after radiation is the source of continued distress. In 2019, the patient required fulguration for bleeding and overactive bladder. His provider has recommended …”
“Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for hyperbaric therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s chronic non-healing radiation induced wound and osteomyelitis of scalp bone.Findings: There is sufficient support in the medical literature and in the submitted documentation …”
“A 22-year-old female enrollee has requested for hyperbaric oxygen treatment for treatment of her squamous cell carcinoma. Findings: Two physician reviewers found that a recent Cochrane Database report analyzing all available evidence for hyperbaric oxygen treatment in patients with late radiation tissue injury concluded that this treatment is associated with improved outcomes in patients with late radiation tissue injury of …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for hyperbaric oxygen therapy (HBOT) in a medical-grade hyperbaric monoplace chamber. Based on the available records, the flap failure and necrosis described in this patient’s clinical setting are known possible side effects that providers can manage with various interventions. However, HBOT in a monoplace chamber …”
- 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 Hyperbaric O2 Chamb denials for Cancer overturned?
In 8 California IMR decisions from 2005 to 2024, reviewers overturned 5 (62.5%). In the last five years: 0.0% of 2. 5 were medical-necessity disputes, 3 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.