Non-FDA Approved Use for Cardiac/Circ Problem: 57.1% of denials overturned
In 7 California IMR decisions from 2005 to 2010, reviewers overturned 4 (57.1%). 6 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
From recent overturned decisions
“A 67-year-old male enrollee has requested Plavix, 150 mg daily (60 doses of 75 mg tablets) for treatment of his medical condition. Findings: The physician reviewer found that it is becoming standard clinical practice to test for Plavix responsiveness in individual patients by genotyping for cytopchrome P-450 enzymatic activity. The current clinical approach to those patients shown to exhibit resistance …”
“A 49-year-old male enrollee has requested for Lyrica for treatment of his painful paresthesias. Findings: The physician reviewer found that there are two randomized controlled trials that have demonstrated statistically significant improvement in pain levels with the use of Lyrica in patients with central pain syndromes. An article by Gray states that Lyrica has been shown to be efficacious in …”
“A 55-year-old male enrollee has requested for Lovaza (6g/day) for treatment of his hypertriglyceridemia. Findings: The physician reviewer found that there are no other viable alternatives and since he has had a marked favorable response to 4 grams, it is reasonable and appropriate to try a higher dosage (6 grams/day) to see if it will result in any further reductions …”
And one the reviewer upheld
“A 52-year-old female enrollee has requested for Lyrica for treatment of her condition. Findings: The physician reviewer found that the medical literature does not support the use of Lyrica for post-stroke pain. A systematic review of the literature on the pharmacologic treatment of central post-stroke pain showed that amitriptyline and lamotrigine are the only oral medications that have proven to …”
- 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 Cardiac/Circ Problem overturned?
In 7 California IMR decisions from 2005 to 2010, reviewers overturned 4 (57.1%). 6 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.