Inpt Early Discharge for Cardiac/Circ Problem: 27.3% of denials overturned
In 11 California IMR decisions from 2007 to 2018, reviewers overturned 3 (27.3%). 11 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“A 49-year-old male enrollee has requested rehabilitation at a skilled nursing facility for the treatment of his medical condition. Findings: The physician reviewer found that the medical literature indicates that recovery after stroke occurs fastest in the first three months. Later recovery (up to one to two years after stroke) is also possible, especially between three to six months. Therefore, …”
“The representative of a deceased 64-year-old male enrollee has requested for skilled nursing facility (SNF) services for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that the patient was in worse condition in terms of PT and OT performance. He regressed from contact guard assist with PT to minimum assist of two and from moderate assist with …”
“The daughter of a 91-year-old female enrollee has requested continued stay at a skilled nursing facility (SNF) for treatment of a fracture of the humeral head and neck and two strokes. Findings: The physician reviewer found that the patient had a gastrostomy tube and received all of her nutritional support via the tube feedings. Her feedings were managed by the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and continuous coverage of a skilled nursing facility, level II care from 8/22/18 forward. Per a study, mild to moderate nonpurulent skin/soft tissue infections such as limb cellulitis are treated with intravenous and/or oral antibiotics. Another study note that lymphedema is a chronic condition that is managed with interventions such …”
- 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 Early Discharge denials for Cardiac/Circ Problem overturned?
In 11 California IMR decisions from 2007 to 2018, reviewers overturned 3 (27.3%). 11 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.