Ongoing OON Tx for CNS/ Neuromusc Dis: 75.0% of denials overturned
In 8 California IMR decisions from 2003 to 2016, reviewers overturned 6 (75.0%). 8 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurofeedback three times per week, eye movement desensitization and reprocessing (EMDR) twice per week and one on one psychiatric therapy for treatment of the enrollee’s brain injury. Findings: The physician reviewer found that The use of neurofeedback and EMDR are beneficial and medically appropriate in patients who …”
“A 43-year-old male enrollee requested post-acute neuro/brain rehabilitation for medical treatment of his traumatic brain injury (TBI). Findings: The physician reviewer found that the patient has had substantial neurocognitive residuals from TBI, with impaired concentration and cognitive fatigue. He has completed acute rehab, skilled nursing facility rehabilitation, and home therapies. He has potential for further gains as noted by neuropsychological …”
“The parent of a 15-year-old female enrollee has requested a seven-day video EEG monitoring to be performed by a pediatric epilepsy center and follow-up care and treatment with a pediatric neurologist (epileptologist) and a pediatric neurosurgeon for treatment of the enrollee’s medically intractable epilepsy. Findings: The physician reviewer found that the patient has medically refractory epilepsy. Surgical treatment is a …”
And one the reviewer upheld
“A 52-year-old female enrollee requested for continued Cerezyme infusion therapy for treatment of her Gaucher’s disease. Findings: The physician reviewer found that the elevated blood pressure does not represent an emergency and is not beyond what a person may experience with anxiety. There are a number of ways of dealing with anxiety. People often experience anxiety when undergoing medical procedures. …”
- 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 CNS/ Neuromusc Dis overturned?
In 8 California IMR decisions from 2003 to 2016, reviewers overturned 6 (75.0%). 8 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.