OON/ Acad Ctr Ref for Cancer: 41.9% of denials overturned
In 31 California IMR decisions from 2003 to 2016, reviewers overturned 13 (41.9%). 23 were medical-necessity disputes, 7 experimental/investigational, 1 urgent care.
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% | 41.9% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 3 | 33.3% | 41.9% |
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 …”
And one the reviewer upheld
“A 63-year-old female enrollee has requested coverage for past hospitalization services provided at Contra Costa Regional Medical Center. The Health Plan has denied this request indicating that the services at issue were out-of-plan post-stabilization care. Findings: The physician reviewer found that the presentation of acute leukemia includes symptoms of relatively short duration, including fever, fatigue, and bleeding. In this patient’s …”
- 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 for Cancer overturned?
In 31 California IMR decisions from 2003 to 2016, reviewers overturned 13 (41.9%). 23 were medical-necessity disputes, 7 experimental/investigational, 1 urgent care.
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.