Inpt Admission for Skin Disorders: 33.3% of denials overturned
In 6 California IMR decisions from 2006 to 2022, reviewers overturned 2 (33.3%). In the last five years: 100.0% of 1. 6 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) level of care. Findings: As noted in the medical literature, SNF admission may be indicated for patients with more than one wound, including a stage 3 pressure ulcer, rehabilitation, gait training, and observation. One study noted that, “Pressure ulcers (PUs) are injuries to …”
“The spouse of a deceased female enrollee has requested skilled nursing facility care for treatment of her metastatic breast cancer. Findings: The physician reviewer found the submitted documentation supports the medical necessity of the services at issue. In this patient’s case, skilled nursing facility care was medically indicated and consistent with generally accepted guidelines. The submitted records document several issues …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services including daily wound care and physical therapy. The specialized skill, knowledge and judgment of a skilled professional nurse has not been required to safely and effectively provide medically necessary and reasonable treatment to this patient. This patient’s wound care is …”
- 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 Inpt Admission denials for Skin Disorders overturned?
In 6 California IMR decisions from 2006 to 2022, reviewers overturned 2 (33.3%). In the last five years: 100.0% of 1. 6 were medical-necessity disputes.
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.