MRI for Not Applicable: 50.0% of denials overturned
In 6 California IMR decisions from 2003 to 2017, reviewers overturned 3 (50.0%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging for evaluation of the enrollee’s chronic elbow pain. Findings: The physician reviewer found that for this patient, a repeat MRI was indicated. The MRI done earlier was interpreted with less than definitive findings. In addition, the pediatric orthopedist felt that the MRI appeared normal. Imaging of …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging for evaluation of the enrollee’s headaches. Findings: The physician reviewer found that evidence based medical guidelines support MRI of the brain in this clinical setting. The National Imaging Association (NIA) clinical guidelines specify MRI of the brain for headaches lasting more than a few minutes when …”
“A 35-year-old female enrollee requested authorization and coverage of an MRI of the brain. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollee’s numbness and tingling sensations.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plan’s denial on the basis that the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the chest. Findings: The physician reviewer found that the American College of Radiology (ACR) lists MRI of the chest in a patient with likely non-cardiogenic chronic chest pain as having a relative value of 2/9 which is low on the probability …”
- 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 Not Applicable overturned?
In 6 California IMR decisions from 2003 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.