Lab Work for Respiratory System: 60.0% of denials overturned
In 10 California IMR decisions from 2010 to 2020, reviewers overturned 6 (60.0%). , 10 experimental/investigational.
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 | 100.0% | 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
“Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for nitric oxide expired gas determination. The enrollee has asthma. She has been on Albuterol, Advair, and Combivent. She was evaluated by her pulmonologist due to complaints of a dry cough and shortness of breath with exertion. She has a history of vocal cord polyps and hoarseness, secondary to increased …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the IgG testing (CPT code 83516). As noted in the current peer-reviewed medical literature, this panel of laboratory testing is important in the diagnosis of myopathies and myositis. These tests can help facilitate a treatment pathway by diagnosing the various phenotypes associated with these diseases. In this clinical setting, …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for allergy testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of food allergies.Findings: There is support for the services at issue in this clinical setting. The use of food …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee have requested reimbursement for allergy testing. The Chronic Urticaria (CU) Index is an in vitro basophil (leukocyte) histamine release assay in which patient serum is mixed with donor basophils and the released histamine levels are measured through a quantitative enzyme immunoassay. A CU Index value greater than or equal to …”
- 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 Respiratory System overturned?
In 10 California IMR decisions from 2010 to 2020, reviewers overturned 6 (60.0%). , 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.