Invest Tx Protocol denials: 56.0% overturned by independent reviewers
In 25 California IMR decisions from 2003 to 2011, reviewers overturned the plan 14 times (56.0%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Immuno Disorders | 5 | 60.0% | — |
| Cancer | 5 | 60.0% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 15 | 53.3% | 56.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 66.7% | 56.0% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 66.7% | 56.0% |
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
“A 50-year-old male enrollee has requested Provigil 600mg per day for treatment of his bipolar disorder, attention deficit/hyperactivity disorder and obstructive sleep apnea. Findings: Three physician reviewers found that this patient has had significant overall improvement with this dose of Provigil. There is documentation that this medication dose has had positive improvement, without adverse effects from the medication. A significant …”
“A 55-year-old female enrollee has requested for Thalomid for treatment of her condition. Findings: Two physician reviewers found that there is no standard therapy for metastatic islet cell cancer. A phase II study of the combination of thalidomide and temzolomide revealed a very promising degree of clinical activity. For this disease with no standard treatment options, this combination is promising.”
“A 48-year-old female enrollee has requested intravitreal Avastin injections for the treatment of her recurrent vitreous hemorrhage. Findings: Three physician reviewers found that although originally studied for the treatment of wet (age-related) macular degeneration, Avastin has been effective in other ocular applications such as PDR. Avastin therapy is widely accepted among practitioners in this specialty area. The patient’s vitreous hemorrhage …”
- 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 Invest Tx Protocol denials overturned?
In 25 California IMR decisions from 2003 to 2011, reviewers overturned the plan 14 times (56.0%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.