Mammoplasty for OB-GYN/ Pregnancy: 62.5% of denials overturned
In 16 California IMR decisions from 2002 to 2018, reviewers overturned 10 (62.5%). 16 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for reduction mammoplasty. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient’s macromastia and are not reconstructive in nature. This patient has well-documented chronic back and neck pain as well as shoulder grooving. This has significantly …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested the surgical procedure, reduction mammoplasty for treatment of her macromastia. Findings: The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested surgery. According to the American Society of Plastic Surgeon’s (ASPS) guidelines “Based on the results of Level I and II …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested an office consultation with a plastic surgeon for evaluation of her hypertrophy of breast. Findings: The physician reviewer found that the submitted documentation supports the medical necessity for the requested consultation. The patient’s clinical condition warrants an evaluation by a plastic surgeon. Per the record, this patient has severe symptomatic macromastia …”
And one the reviewer upheld
“A 48-year-old female enrollee requested breast augmentation revision surgery (removal of capsular scar tissue and bilateral implants for treatment of her partially deflated bilateral saline breast implants. Findings: The physician reviewer found that the patient is noted to have possible bilateral saline implant rupture following augmentation mastopexy. Based on the submitted documentation, there is no evidence that the breast augmentation …”
- 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 Mammoplasty denials for OB-GYN/ Pregnancy overturned?
In 16 California IMR decisions from 2002 to 2018, reviewers overturned 10 (62.5%). 16 were medical-necessity disputes.
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.