Mammography for OB-GYN/ Pregnancy: 91.7% of denials overturned
In 242 California IMR decisions from 2006 to 2017, reviewers overturned 222 (91.7%). 3 were medical-necessity disputes, 239 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. | 79 | 91.1% | 91.7% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 36 | 100.0% | 91.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 0.0% | 91.7% |
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 breast magnetic resonance imaging (MRI) provided for evaluation of the enrollee, who had an abnormality on a mammogram. Findings: The 3 physician reviewers found that there is sufficient support for the services at issue in this clinical setting. In this case, mammograms clearly showed a new area of abnormality. …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her risk for breast cancer. Findings: Three physician reviewers found that in the peer-reviewed medical literature, researchers found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography “resulted in a significantly higher cancer detection rate and enabled …”
“Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the bilateral digital breast tomosynthesis. Findings: The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee’s medical condition. Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did …”
- 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 Mammography denials for OB-GYN/ Pregnancy overturned?
In 242 California IMR decisions from 2006 to 2017, reviewers overturned 222 (91.7%). 3 were medical-necessity disputes, 239 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.