Non-FDA Approved Use for Endocrine/Metabolic: 76.5% of denials overturned
In 17 California IMR decisions from 2003 to 2010, reviewers overturned 13 (76.5%). 16 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
From recent overturned decisions
“A 34-year-old female enrollee has requested for the medication Glumetza for treatment of her medical condition. Findings: The physician reviewer found that Gastrointestinal (GI) side effects, are well-known in relation to generic metformin, regular or extended release. These GI issues limit their use in individuals such as this patient. In this patient’s particular clinical situation, Glumetza would be a superior …”
“The parent of a 14-year-old male enrollee has requested for Femara 2.5mg for treatment of the enrollee’s short stature. Findings: Three physician reviewers found that there is adequate evidence in the peer-reviewed medical literature to support the efficacy of aromatase inhibitors for individuals such as this patient. Femara 2.5mg is likely to be more beneficial for treatment of the patient’s …”
“A 64-year-old female enrollee has requested Provigil 100 mg for the treatment of her Addison’s disease and Schmidt’s syndrome. Findings: The physician reviewer found that Provigil is effective in the treatment of excessive somnolence and fatigue associated with sleep disorders including narcolepsy, idiopathic hypersomnolence, obstructive sleep apnea controlled with CPAP, and shift-work sleep disorder. Provigil is also used as an …”
And one the reviewer upheld
“A 51-year-old male enrollee has requested Arimidex for the treatment of his hypogonadotropic hypogonadism. Findings: The physician reviewer found that Arimidex is being used to block the excess production of estrogen seen in patients with a large excess of adiopose tissue. The advantage of Arimidex was not in the treatment of the hypogonadism (which can be treated with testosterone) but …”
- 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 Endocrine/Metabolic overturned?
In 17 California IMR decisions from 2003 to 2010, reviewers overturned 13 (76.5%). 16 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.