OON Referral for Cardiac/Circ Problem: 30.0% of denials overturned
In 10 California IMR decisions from 2005 to 2024, reviewers overturned 3 (30.0%). In the last five years: 33.3% of 3. 10 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2023 | 1 | 100.0% |
| 2024 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 25.0% | 30.0% |
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: The patient has requested authorization and coverage for a referral to a multidisciplinary autonomic program that includes Neurology, Cardiology, Gastroenterology, Pain Medicine, Rheumatology, Immunology, Hematology, Dermatology, Psychiatry, and Pathology specializing in autonomic disorders. A multidisciplinary autonomic program is an interdisciplinary program that provides collaborative and comprehensive care for patients with disorders of the autonomic nervous …”
“A 54-year-old male enrollee has requested for diagnostic cardiac catheterization with coronary angiography and subsequent treatment for treatment of his medical condition. Findings: The physician reviewer found that the likelihood of significant obstructive coronary disease is high, such that planning for possible percutaneous coronary intervention concomitant with a diagnostic coronary angiography is reasonable, appropriate and medically less risky compared to …”
“The parent of a 28-year-old female enrollee has requested highly specialized surgical services for the treatment of her Barlow’s disease. Findings: The physician reviewer found that the patient has severe mitral regurgitation secondary to Barlow’s disease. She will require complex repair with sliding annuloplasty. This can only be done by a specialist in mitral repair. The requested services are medically …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for complete decongestive therapy with a certified lymphatic therapist for lymphedema treatment consisting of two phases of treatment (Phase I: a) Intensive therapy involving 60 minute sessions for 4-5 days a week for manual lymphatic drainage/massage. b) Adjustments of compression wraps/bandages (enrollee has these items already at home …”
- 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 Referral denials for Cardiac/Circ Problem overturned?
In 10 California IMR decisions from 2005 to 2024, reviewers overturned 3 (30.0%). In the last five years: 33.3% of 3. 10 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.