OON/ Acad Ctr Ref denials: 42.4% overturned by independent reviewers
In 33 California IMR decisions from 2003 to 2016, reviewers overturned the plan 14 times (42.4%). 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 |
|---|---|---|---|
| Cancer | 31 | 41.9% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 8 | 37.5% | 42.4% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 3 | 33.3% | 42.4% |
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: An enrollee has requested treatment in a comprehensive cancer treatment center for treatment of her medical condition. Findings: The physician reviewer found that the patient presents with an aggressive and rare cancer and was appropriately evaluated and treated at a large cancer center that has extensive experience in interdisciplinary care. Special cancer centers with such …”
“A 64-year-old male enrollee has requested reimbursement for services provided on an emergent basis. Findings: The physician reviewer found that the patient is a 64-year-old male who underwent urgent/emergent evaluation, resuscitation and bladder tumor resection and fulguration. The pathology specimen showed high grade transitional cell carcinoma and although the operative report states resection was carried out through to the perivesical …”
“A 49-year-old female enrollee has requested cytoreduction surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of her cecal cancer. Findings: Two physician reviewers found that this patient is sensitive to various chemotherapies and has a tumor that is restricted to the pelvis that is amenable to surgery and HIPEC. HIPEC has followed debulking surgery in the series that have been …”
- 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 OON/ Acad Ctr Ref denials overturned?
In 33 California IMR decisions from 2003 to 2016, reviewers overturned the plan 14 times (42.4%).
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.