Lab Work for Not Applicable: 50.0% of denials overturned
In 10 California IMR decisions from 2014 to 2017, reviewers overturned 5 (50.0%). , 10 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 33.3% | 50.0% |
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
“Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the genetic testing performed.Findings: The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test performed for evaluation of her pregnancy at advanced maternal age. Findings: Three physician reviewers found that the American College of Obstetrics and Gynecology (ACOG) recommends patients undergo non-invasive prenatal testing, especially in the high risk setting. ACOG endorses the discussion and use of non-invasive prenatal testing …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for cancer susceptibility. Findings: The physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines, patients who are “meeting one or more of these criteria warrants further personalized risk assessment, genetic counseling, and often genetic testing and management.” In this case, the patient …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the advanced lipoprotein testing for evaluation of the enrollee’s risk for heart disease. Findings: Three physician reviewers found that this patient presents with baseline elevation of low density lipoprotein (LDL) cholesterol and non-high density lipoprotein (HDL) cholesterol but with negative risk factor of high HDL cholesterol. Advanced lipoprotein markers …”
- 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 Not Applicable overturned?
In 10 California IMR decisions from 2014 to 2017, reviewers overturned 5 (50.0%). , 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.