IVIG Therapy for Infectious Disease: 18.2% of denials overturned
In 11 California IMR decisions from 2002 to 2024, reviewers overturned 2 (18.2%). In the last five years: 25.0% of 4. 6 were medical-necessity disputes, 5 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 3 | 33.3% |
| 2024 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 7 | 14.3% | 18.2% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG). As noted in the medical literature, RANBP2 resulting in recurrent episodes acute necrotizing encephalitis type 1 does not have an established standard therapy. Overall, there is a lack of controlled clinical trials or guidelines from the Child Neurology Society or American Academy …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen 500 mg IVIG therapy. The submitted documentation supports the medical necessity of the requested treatment. BK viremia is associated with poorer outcomes with renal allografts. The risks of allograft failure are great. IVIG therapy is considered standard of care for this particular condition and has been …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for laboratory services. The patient resides in an endemic area for the pathogens tested. The patient’s history of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is not a reason to avoid testing for other causes of fever such as tick-borne infections following a tick …”
- 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 IVIG Therapy denials for Infectious Disease overturned?
In 11 California IMR decisions from 2002 to 2024, reviewers overturned 2 (18.2%). In the last five years: 25.0% of 4. 6 were medical-necessity disputes, 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.