Hyperbaric O2 Chamb for Ears/Nose/Throat: 31.3% of denials overturned
In 16 California IMR decisions from 2010 to 2023, reviewers overturned 5 (31.3%). In the last five years: 50.0% of 4. 4 were medical-necessity disputes, 12 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 2 | 50.0% |
| 2023 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 11 | 27.3% | 31.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 25.0% | 31.3% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy service. Current medical literature supports the use of hyperbaric oxygen therapy for the treatment of idiopathic sudden sensorineural hearing loss. Researchers note that there is clinically meaningful improvement with the use of hyperbaric oxygen therapy in patients with moderate …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for hyperbaric oxygen therapy (CPT 99183 and HCPCS G0277) for 30 total treatments of 90 minutes (four segments per treatment) once daily for five (5) days per week. The submitted documentation supports the medical necessity of a portion of the services at issue. Hyperbaric oxygen …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Hyperbaric Oxygen Treatment.Findings: Two out of three physician reviewers found that the services at issue were likely to have been more beneficial than any available standard treatment for the patient’s medical condition. According to the American Academy of Otolaryngology-Head and Neck Surgery, when a patient presents with sudden sensorineural …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for hyperbaric oxygen therapy (HBOT). The patient has reported sudden hearing loss on 1/20/22. The patient’s provider recommended treatment with HBOT. However, the evidence in the medical literature supporting treatment of sudden hearing loss with HBOT remains limited. Hosokawa and colleagues evaluated the outcomes and …”
- 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 Ears/Nose/Throat overturned?
In 16 California IMR decisions from 2010 to 2023, reviewers overturned 5 (31.3%). In the last five years: 50.0% of 4. 4 were medical-necessity disputes, 12 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.