Mammography for Prevention/Good Hlth: 93.9% of denials overturned
In 473 California IMR decisions from 2014 to 2019, reviewers overturned 444 (93.9%). 3 were medical-necessity disputes, 470 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 121 | 99.2% | 93.9% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 114 | 93.0% | 93.9% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 93.9% |
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: Physical examination revealed that the patient’s breasts were without masses. The patient underwent a mammogram, and the results were negative for any suspicious abnormalities. The patient’s breast tissue was noted to be dense. In the independent medical review application, the patient reported she has a family history of breast cancer. The patient has requested reimbursement …”
“Nature of Statutory Criteria/Case Summary: The patient underwent genetic testing, which revealed a BRCA1 mutation of uncertain clinical significance. She has a calculated lifetime risk of 27.7% of developing breast cancer utilizing the Tyrer-Cusick model. Repeat genetic testing utilizing the International Breast Intervention Study (IBIS) model revealed the patient had a 12.3% lifetime risk of developing breast cancer. Magnetic resonance …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a three-dimensional (3D) mammogram for evaluation of her breast cancer. Findings: The physician reviewer found that although tomosynthesis is not routinely used as a part of screening mammography, this patient has unique circumstances. First, the patient’s breast tissue has been described as heterogeneously dense which limits the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her breast cancer examination. Findings: Two physician reviewers found that There is a lack of peer-reviewed literature that supports the use of digital breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is …”
- 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 Prevention/Good Hlth overturned?
In 473 California IMR decisions from 2014 to 2019, reviewers overturned 444 (93.9%). 3 were medical-necessity disputes, 470 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.