Non-FDA Approved Use for Blood Related Disord: 50.0% of denials overturned
In 10 California IMR decisions from 2004 to 2009, reviewers overturned 5 (50.0%). 9 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
From recent overturned decisions
“A 56-year-old female enrollee has requested Procrit for the treatment of her anemia. Findings: The physician reviewer found that anemia of chronic disease (ACD) is commonly seen in patients with chronic infection, inflammation, or malignancy. It is a mild normocytic normochromic anemia, with low levels of serum iron and transferrin, normal to increased serum levels of ferritin, normal to increased …”
“A 28-year-old female enrollee has requested coverage for Rituxan therapy for treatment of her idiopathic thrombocytopenia purpura (ITP). Findings: The physician reviewer found that patients with ITP that relapse despite IVIG and/or WinRho and who no longer respond to steroids, often require splenectomy. Rituxan is a well-established alternative to splenectomy and is fast becoming “standard of care” in this setting. …”
“A 43-year-old male has requested rituximab for treatment of Wegener’s granulomatosis. Findings: Two physician reviewers found that review of the medical literature reveals many reports of uncontrolled use of rituximab with benefit for WG in patients who have failed cyclophosphamide. The use of rituximab for the treatment of WG is now standard practice in rheumatology given the life-threatening nature of …”
And one the reviewer upheld
“A 74-year-old female enrollee has requested Procrit for the treatment of her anemia secondary to diabetes mellitus. Findings: The physician reviewer found that since the cause of the anemia has not been medically evaluated for possible causes, such as chronic renal failure with loss of endogenous erythropoietin, underlying cancer, or other marrow disorders, it is not possible to conclude that …”
- 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 Non-FDA Approved Use denials for Blood Related Disord overturned?
In 10 California IMR decisions from 2004 to 2009, reviewers overturned 5 (50.0%). 9 were medical-necessity disputes, 1 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.