Lab Work for Genetic Diseases: 46.7% of denials overturned
In 15 California IMR decisions from 2008 to 2021, reviewers overturned 7 (46.7%). In the last five years: 0.0% of 1. 5 were medical-necessity disputes, 10 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 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. | 3 | 0.0% | 46.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 46.7% |
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 has requested authorization and coverage for genetic testing (HHT panel) for evaluation of the enrollee’s capillary malformation arteriovenous malformation (CM-AVM). Findings: The physician reviewer found that HHT is a genetic disease that causes multiple arteriovenous malformations in various organs. Common presentations include epistaxis, mucocutaneous arteriovenous malformations, and/or gastrointestinal bleeding. The genetic testing as …”
“Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the gene panel testing services for evaluation of the enrollee’s carrier status. Findings: The physician reviewers found that As noted by the American College of Obstetricians and Gynecologists (ACOG), early “prenatal genetic testing focused primarily on Down syndrome , but now it is able to detect a broad range of …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory tests received for evaluation of the enrollee’s family history of rhizomelic chondrodysplasia punctate 1 (RCDP1). Findings: Three physician reviewers have found that RCDP1 is a condition that impairs the normal development of many parts of the body. The major features of this disorder include skeletal abnormalities, joint deformities, …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for qualitative or semiquantitative immunoassay testing (CPT 86352) provided by Moleculera Labs, Inc. The records provided for review document that this patient has undergone treatment with one medication trial, Sertraline, for management of his obsessive-compulsive disorder (OCD) and anxiety. Per the medical literature and The International College of Obsessive-Compulsive Spectrum …”
- 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 Lab Work denials for Genetic Diseases overturned?
In 15 California IMR decisions from 2008 to 2021, reviewers overturned 7 (46.7%). In the last five years: 0.0% of 1. 5 were medical-necessity disputes, 10 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.