MRI for OB-GYN/ Pregnancy: 40.8% of denials overturned
In 103 California IMR decisions from 2002 to 2018, reviewers overturned 42 (40.8%). 41 were medical-necessity disputes, 62 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 23 | 39.1% | 40.8% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 10 | 0.0% | 40.8% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 5 | 60.0% | 40.8% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 4 | 75.0% | 40.8% |
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 (MRI) of the breasts. Findings: Two of the three physician reviewers found breast MRI has an important role in both screening and diagnostic settings. There are multiple clinical considerations in which MRI has become widely used. These include areas of asymmetry, architectural distortion, and …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of the enrollee’s medical condition. Findings: Two physician reviewers found that this patient has heterogeneously dense tissue on mammography which is known to limit the usefulness of standard mammography. The pathologic diagnosis of cellular atypia is a finding most pathologists consider to be a …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee’s medical condition. Findings: The physician reviewers found that Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bilateral MRI of the breast. ACR’s updated guidelines suggest that, in the presence of a palpable mass, the next step should be biopsy or tissue sampling. ACR’s algorithm for management of a patient with a palpable breast mass who is over 40 years of age indicates …”
- 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 OB-GYN/ Pregnancy overturned?
In 103 California IMR decisions from 2002 to 2018, reviewers overturned 42 (40.8%). 41 were medical-necessity disputes, 62 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.