IDET for Orth/Musculoskeletal: 7.1% of denials overturned
In 28 California IMR decisions from 2002 to 2016, reviewers overturned 2 (7.1%). 3 were medical-necessity disputes, 25 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 23 | 8.7% | 7.1% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 16.7% | 7.1% |
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
“Physician 1: The patient is a 22-year-old woman with a history of juvenile lumbar disc disease. She had undergone conservative treatments with no long-term benefit. The patient’s provider has recommended the patient undergo an IDET procedure, which was performed in November 2003. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.IDET remains …”
“Physician 1The patient is a 42-year-old female with chronic discogenic low back pain secondary to internal disc derangement at L4-5 and L5-6. The patient underwent provocation discography on 8/17/04 demonstrating diffuse annular disruption at L4-5 and midline radial fissure at L5-6. The patient’s provider has recommended the patient undergo an intradiscal electrothermal therapy (IDET) procedure. The Health Plan indicates the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested intradiscal electrothermal annuloplasty (IDET) for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Despite the large number of procedures performed, a critical appraisal of the evidence of efficacy of IDET demonstrates that the evidence for …”
- 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 IDET denials for Orth/Musculoskeletal overturned?
In 28 California IMR decisions from 2002 to 2016, reviewers overturned 2 (7.1%). 3 were medical-necessity disputes, 25 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.