Lab Work for OB-GYN/ Pregnancy: 38.7% of denials overturned
In 62 California IMR decisions from 2006 to 2018, reviewers overturned 24 (38.7%). 9 were medical-necessity disputes, 51 experimental/investigational, 2 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 18 | 38.9% | 38.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 10 | 40.0% | 38.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 16.7% | 38.7% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 5 | 60.0% | 38.7% |
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 reimbursement for the gene test. According to medical research, given the performance of conventional screening methods, the limitations of cell free DNA screening performance and the limited data on cost effectiveness in the low risk obstetrical population, conventional screening methods remain the most appropriate choice for first-line screening for most women …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings: Two of the three physician reviewers found that the submitted documentation supports a portion of the services at issue. The American College of Obstetricians and Gynecologists recommends that screening for spinal muscular atrophy and cystic fibrosis should be offered to all women who are considering pregnancy …”
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for genetic tests for Ashkenazi Jewish associated disorders that were performed on 11/03/17. Findings: The physician reviewer found that the services at issue were likely to be more beneficial for the evaluation of the patient’s medical condition than any available standard therapy. The patient is of Ashkenazi Jewish descent and …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure testing.Findings: Three physician reviewers found that the services in issue were not indicated under these circumstances. The determination of ROM during pregnancy is very important to determine next steps in management. In clinical practice, the diagnosis of rupture of membranes can sometimes be difficult and equivocal. The American …”
- 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 OB-GYN/ Pregnancy overturned?
In 62 California IMR decisions from 2006 to 2018, reviewers overturned 24 (38.7%). 9 were medical-necessity disputes, 51 experimental/investigational, 2 urgent care.
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.