Interferon for CNS/ Neuromusc Dis: 50.0% of denials overturned
In 6 California IMR decisions from 2008 to 2018, reviewers overturned 3 (50.0%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: A 48-year-old female enrollee has requested authorization and coverage for Avonex. Findings: The physician reviewer found that Avonex is U.S. Food and Drug Administration (FDA) approved and has been demonstrated to be effective in the treatment of MS. Avonex has been shown to reduce relapses and disability progression. Studies show interferons are similar efficacy to …”
“A male enrollee requested Plegridy for medical treatment of his multiple sclerosis. Findings: The physician reviewer found that as this patient has been having significant breakthrough disease on Copaxone, he needs to be treated with another disease modifying agent. Plegridy is a medication that is U.S. Food and Drug Administration (FDA) approved for treatment of relapsing forms of multiple sclerosis. …”
“A 55-year-old female enrollee has requested for Betaseron 0.3mg vial for treatment of her multiple sclerosis (MS). Findings: The physician reviewer found that there are four, injectable disease-nullifying agents (Avonex, Betaseron, Rebif, and Copaxone). All of these agents have relatively similar efficacy depending on the study and their endpoint. What is most important is that the patient starts one of …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Plegridy syringe. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Although Plegridy has been shown to reduce disease activity in relapsing-remitting multiple sclerosis, the current medical evidence has not demonstrated that this medication is more efficacious …”
- 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 Interferon denials for CNS/ Neuromusc Dis overturned?
In 6 California IMR decisions from 2008 to 2018, reviewers overturned 3 (50.0%). 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.