Ongoing OON Tx for Digestive System/ GI: 20.0% of denials overturned
In 5 California IMR decisions from 2005 to 2022, reviewers overturned 1 (20.0%). In the last five years: 0.0% of 1. 4 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“An enrollee has requested reimbursement for four Barrx Ablation Procedures that have been performed, and has requested authorization and coverage for the Barrx ablation procedure. Patients with family history of esophageal cancer have a predilection for esophageal cancer themselves. The risk of esophageal cancer in a patient with two first-degree relatives who have esophageal cancer (defined as familial Barretts esophagus) …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for functional medicine visits. The medical evidence does not support the requested services in this patient’s case. There are guidelines for the management of gastroesophageal reflux disease and dyspepsia, which recommend medical therapy followed by, if indicated, endoscopic evaluation. The request for the use of …”
- 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 Digestive System/ GI overturned?
In 5 California IMR decisions from 2005 to 2022, reviewers overturned 1 (20.0%). In the last five years: 0.0% of 1. 4 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.