MRI for Chron Pain Synd: 50.0% of denials overturned
In 6 California IMR decisions from 2015 to 2017, reviewers overturned 3 (50.0%). 6 were medical-necessity disputes.
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 | 33.3% | 50.0% |
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: An enrollee has requested authorization and coverage for magnetic resonance imaging of the spine (MRI). Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Over the years, the American College of Radiology (ACR) has established appropriateness guidelines, directing appropriate evaluation of various common conditions. In 1998, …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging for evaluation of the enrollee’s severe major osteoporotic fracture. Findings: The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Studies have shown that at autopsy, as many as 90% of patients with cancer have evidence of …”
“A 65-year-old female enrollee has requested magnetic resonance imaging (MRI) of the lower extremity joint without dye for evaluation of her left knee pain. Findings: The physician reviewer found that based on the available medical records, this patient has clinical evidence to justify MRI exam of the left knee as mentioned in the National Imaging Associates (NIA) guidelines. Specifically, there …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine and of the neck spine. Findings: The physician reviewer found that the documentation submitted for review does not support a medical indication for the requested diagnostic procedure. There is a lack of support in the peer-reviewed literature supporting the …”
- 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 MRI denials for Chron Pain Synd overturned?
In 6 California IMR decisions from 2015 to 2017, reviewers overturned 3 (50.0%). 6 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.