Nerve Block for Foot Disorder: 60.0% of denials overturned
In 5 California IMR decisions from 2016 to 2021, reviewers overturned 3 (60.0%). In the last five years: 100.0% of 1. , 5 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for seven treatments with Sclerosing injections. Findings: The physician reviewer found that There is long-established research that supports that alcohol sclerosing injections are a viable option in the treatment of intermetatarsal neuroma. Hughes and colleagues conducted a clinical trial in which 101 patients with Morton’s neuroma received an average of …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral nerve block for treatment of the enrollee’s left heel pain. Findings: The physician reviewers found that in the peer-reviewed medical literature, there is a paucity of support for a posterior tibial nerve block prior to a cortisone injection for treatment of plantar fasciitis. The patient was being …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral nerve blocks for treatment of the enrollee’s right foot pain. Findings: The physician reviewers found that treatment for an acute episode of inflammation of the intermetatarsal nerves include shoe changes, orthotics, surgery, and peripheral nerve blocks. This patient has a documented contraindication to treatment with aspirin and …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for injections of dehydrated alcohol solution in the left foot. Sclerosing injections have not been demonstrated to be more beneficial for treatment of neuromas than presently available standard therapies. Studies show inconsistent results that do not demonstrate an improvement in outcomes over traditional therapies. One study evaluated injection …”
- 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 Nerve Block denials for Foot Disorder overturned?
In 5 California IMR decisions from 2016 to 2021, reviewers overturned 3 (60.0%). In the last five years: 100.0% of 1. , 5 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.