Non-FDA Approved Use for Skin Disorders: 66.7% of denials overturned
In 12 California IMR decisions from 2002 to 2010, reviewers overturned 8 (66.7%). 12 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“A 44-year-old female enrollee has requested for Protopic 0.1% for treatment of her lichen simplex chronicus. Findings: The physician reviewer found that the requested medication is effective and safe for the treatment of pruritic vulvar disorders, as noted by Goldstein and colleagues and Weisshaar and colleagues. Per Aschoff and colleagues, this has been shown to be effective for lichen simplex …”
“This patient is a 56-year-old man who has moderate to severe psoriasis over at least 20% of his body surface area. He has severe hand and foot involvement, resulting in significant pain and diminishment of function. Treatment over the past seven years has included topical medications, methotrexate, Cyclosporine, systemic and intralesional corticosteroids, Soriatane, Enbrel and Raptiva. Use of each of …”
“The patient is a 68-year-old woman who has severe lichen planopilaris and scarring alopecia of the scalp. Treatments with topical corticosteroids, intralesional kenalog, oral Plaquenil and oral Cellcept have all been unsuccessful. The condition has worsened and the inflammation has become more severe. The patient’s dermatologist prescribed Elidel cream and Clobetasol lotion. The patient’s request for authorization of the Elidel …”
And one the reviewer upheld
“A 50-year-old female enrollee requested authorization and coverage of Tri-Luma cream. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollee’s skin condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plan’s denial on the basis that the requested medication is not medically …”
- 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 Skin Disorders overturned?
In 12 California IMR decisions from 2002 to 2010, reviewers overturned 8 (66.7%). 12 were medical-necessity disputes.
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.