Hysterectomy for OB-GYN/ Pregnancy: 33.3% of denials overturned
In 54 California IMR decisions from 2002 to 2018, reviewers overturned 18 (33.3%). 52 were medical-necessity disputes, 1 experimental/investigational, 1 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 17 | 0.0% | 33.3% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 7 | 57.1% | 33.3% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 50.0% | 33.3% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 6 | 16.7% | 33.3% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysterectomy. The patient’s symptoms of pain and heaviness, feeling of a knot or ball in the vagina and discharge are consistent with pelvic organ prolapse. She has several risk factors including morbid obesity, chronic cough, and four previous vaginal deliveries. Given her morbid obesity and other …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a hysterectomy for treatment of the enrollee’s uterine prolapse. Findings: The physician reviewer found that the services at issue were medically necessary in this clinical setting. The patient had a complete workup for the etiology of her symptoms. The provider recommended surgical management for treatment of this patient’s uterine …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hysterectomy performed for treatment of the enrollee's menopausal bleeding, uterine fibroids, and bladder adhesions.Findings: The physician reviewer found that postmenopausal bleeding is defined as any bleeding from the genital tract of a woman which occurs after a period of amenorrhea lasting six months or longer. Approximately 10% of …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hysterectomy surgery. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Per current standard of care, a hysterectomy is considered medically necessary for the treatment of abnormal uterine bleeding when investigation has not identified specific etiology of abnormal uterine bleeding through bloodwork and imaging, …”
- 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 Hysterectomy denials for OB-GYN/ Pregnancy overturned?
In 54 California IMR decisions from 2002 to 2018, reviewers overturned 18 (33.3%). 52 were medical-necessity disputes, 1 experimental/investigational, 1 urgent care.
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.