Ongoing OON Tx for Cancer: 50.0% of denials overturned
In 6 California IMR decisions from 2002 to 2024, reviewers overturned 3 (50.0%). In the last five years: 100.0% of 1. 5 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the insertion of a hepatic artery infusion pump. In a meta-analysis of the comparative effectiveness of hepatic artery based therapies for unresectable colorectal liver metastases, researchers conclude, “Hepatic arterial infusion, radioembolization, and transcatheter arterial chemoembolization are equally effective in patients with unresectable colorectal liver metastases with marginal …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services as recommended by Jonathan Goldman, MD including hold osimertinib, start carboplatin/pemetrexed with or without pembrolizumab followed by maintenance pemetrexed with or without pembrolizumab, dexamethasone prior to initiation, folic acid 1 mg tablet, megestrol 40 mg/mL suspension, cyanocobalamin 1000 mcg/mL inject 1000 mcg, and central nervous system …”
“A 58-year-old female enrollee requested authorization and coverage of continued care with a non-contracted oncologist. The enrollee had endometrial adenocarcinoma (uterine cancer) and is three years post-operative. The Health Plan denied the enrollee’s request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plan’s denial …”
And one the reviewer upheld
“A 21-year-old female enrollee requested insulin potentiation therapy and low dose chemotherapy for medical treatment of her ovarian cancer. Findings: Three physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available treatment options. Insulin potentiation therapy and low dose chemotherapy has not been supported by the …”
- 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 Ongoing OON Tx denials for Cancer overturned?
In 6 California IMR decisions from 2002 to 2024, reviewers overturned 3 (50.0%). In the last five years: 100.0% of 1. 5 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.