MRI for Genetic Diseases: 80.0% of denials overturned
In 5 California IMR decisions from 2018 to 2020, reviewers overturned 4 (80.0%). 3 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the spine.The submitted documentation supports the medical necessity of the requested services in this clinical setting. Many studies have reported a high incidence of osteoporosis in patients with Ehlers-Danlos syndrome. Studies reported the prevalence of vertebral fractures in Ehlers-Danlos syndrome patients with …”
“Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement for magnetic resonance spectroscopy (MRS) of the brain (CPT 76390). In this case, MRS was performed as part of a diagnostic work-up in this patient with global developmental delays and microcephaly. Miscevic and colleagues noted that proton MRS, is one of the few techniques for in vivo assessment of …”
“Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for MRI of the spine (CPT 72157, 72156, and 72158). The enrollee is status-post wide excision of a left medial thigh myxoid liposarcoma. Margins of resection were negative. His post-operative course was complicated by development of a seroma, which improved on interventional radiology drain placement and antibiotics, …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A 54-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the wrist. Lynch syndrome is a well-recognized inherited disorder which predisposes the patient to cancer in multiple organs including colon, uterus, stomach, small bowel, pancreas and the urinary tract. A variant known as Muir-Torre syndrome is associated with cutaneous lesions …”
- 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 Genetic Diseases overturned?
In 5 California IMR decisions from 2018 to 2020, reviewers overturned 4 (80.0%). 3 were medical-necessity disputes, 2 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.