Not Applicable denials: 46.7% overturned by independent reviewers
In 30 California IMR decisions from 2009 to 2017, reviewers overturned the plan 14 times (46.7%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Not Applicable | 6 | 0.0% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 33.3% | 46.7% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 40.0% | 46.7% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for implantation of a cranial nerve neurostimulator for treatment of the enrollee’s obstructive sleep apnea. Findings: The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the special wound product called xenograft that was used for surgery performed for treatment of the enrollee’s burns to her upper right arm.Findings: The three physician reviewers found that xenografting in the use of burn wound care is not investigational. The available literature concludes that xenografting …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Alimentum formula along with PediaSure for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that records provided for review document that this patient is dependent upon formula for her nutrition. She has multiple food allergies and oral intolerance, requiring a specific …”
- 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 Not Applicable denials overturned?
In 30 California IMR decisions from 2009 to 2017, reviewers overturned the plan 14 times (46.7%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.