Hyperbaric O2 Chamb for Endocrine/Metabolic: 60.0% of denials overturned
In 5 California IMR decisions from 2009 to 2022, reviewers overturned 3 (60.0%). In the last five years: 66.7% of 3. 4 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2022 | 2 | 50.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for wound excision and more minimal debridement of the underlying osteomyelitis bone with hyperbaric oxygen therapy (HBOT) and/or intravenous (IV) antibiotic therapy. The records provided for review document that this patient presents with chronic osteomyelitis of the right fourth MTP head and persistent diabetic foot ulcer. The provider …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 sessions of 30-minute hyperbaric oxygen treatment.About 15% to 25% of people with diabetes will develop a foot ulcer. Researchers state that wound infections are a serious potential complication of diabetes and are a known predictor of poor wound healing and amputation. Researchers noted that hyperbaric oxygen …”
“A 55-year-old male enrollee has requested hyperbaric oxygen pressurization for the treatment of his necrotizing fasciitis. Findings: Two physician reviewers found that HBO therapy in a monoplace or multiplace chamber is an accepted treatment in this setting. “Topical” HBO is investigational, but this is not the program that was recommended for this patient. The proposed therapy has established efficacy and …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric chamber wound care treatment. The available records document that this patient presents with a diabetic foot wound that remained non-healing five weeks after incision and drainage. The provider’s description of the patient’s wound suggests that the wound has been slowly improving with traditional therapy. In addition, …”
- 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 Endocrine/Metabolic overturned?
In 5 California IMR decisions from 2009 to 2022, reviewers overturned 3 (60.0%). In the last five years: 66.7% of 3. 4 were medical-necessity disputes, 1 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.