Invest Tx Protocol for Immuno Disorders: 60.0% of denials overturned
In 5 California IMR decisions from 2004 to 2007, reviewers overturned 3 (60.0%). 1 were medical-necessity disputes, 4 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. | 3 | 66.7% | 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 57-year-old female has requested Rituxan for treatment of rheumatoid arthritis. Findings: Two physician reviewers found that the use of Rituxan in this clinical setting is not investigational or experimental. This medication is FDA approved for use in rheumatoid arthritis that has failed methotrexate and at least one tumor necrosis inhibitor medication. She has had an initial response to the …”
“The parent of a 16-year-old male enrollee has requested Remicade for treatment of the enrollee’s idiopathic immunological disorder. Findings: Three physician reviewers found that the patient suffers from a very rare disorder which is not well understood or well controlled at the present time. It is not surprising that Remicade has not been specifically approved for the treatment of such …”
“Physician 1The patient is a 58-year-old woman with a history of fibromyalgia with associated chronic fatigue syndrome and depression since the early 1990’s. The patient has been prescribed many medications including Trazadone, Nortriptyline, Flexeril, Celexa, Zoloft, Ultram, Voltaren, etodolac, and Neurontin. Treatment with these medications provided the patient with significant pain relief but resulted in minimal increase in her energy …”
And one the reviewer upheld
“The patient is a 51-year-old woman with an extensive history of orthopedic and spinal surgery. Her treating physician variously labels her underlying condition as rheumatoid arthritis, psoriatic arthritis, degenerative joint disease, seronegative spondyloarthropathy, B27-positive rheumatoid arthritis, and fibromyalgia. The patient has been treated with an array of agents including DMARD’s, prednisone in fairly high doses, three biologic agents, methotrexate, leflunomide, …”
- 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 Immuno Disorders overturned?
In 5 California IMR decisions from 2004 to 2007, reviewers overturned 3 (60.0%). 1 were medical-necessity disputes, 4 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.