Invest Tx Protocol for Cancer: 60.0% of denials overturned
In 5 California IMR decisions from 2003 to 2008, reviewers overturned 3 (60.0%). , 5 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. | 4 | 50.0% | 60.0% |
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 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.”
“Physician 1: The patient is a 35-year old male found to have an extensive and inoperable carcinoma of the stomach in October 2005. He was started on chemotherapy with Xeloda and Oxaliplatin. The latter drug was denied by the Health Plan as experimental/ investigational for treatment of the patient’s gastric cancer.It is true that Oxaliplatin has only been approved by …”
“A 62-year-old male enrollee requested authorization and coverage of treatment with Celebrex and interferon alpha. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollee’s metastatic renal cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for …”
And one the reviewer upheld
“Physician 1: This patient is a 62-year-old female who was diagnosed with a right upper lobe 5 cm mass in February 2004. First-line treatment was surgery. This was followed by adjuvant treatment consisting of chemotherapy, DDP and navelbine with radiation therapy. The patient experienced a relapse one year out and received second-line chemotherapy with gemcitabine and Taxotere. This was followed …”
- 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 for Cancer overturned?
In 5 California IMR decisions from 2003 to 2008, reviewers overturned 3 (60.0%). , 5 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.