OON Referral for Ears/Nose/Throat: 12.5% of denials overturned
In 8 California IMR decisions from 2002 to 2014, reviewers overturned 1 (12.5%). 8 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“A 51-year-old male enrollee requested authorization and coverage of a nasal endoscopy from an out-of-network provider for treatment of decreased sense of smell and taste. The health plan denied the enrollee’s request indicating that it is not medically necessary for the enrollee to obtain services from the out-of-network provider.One physician reviewer performed a medical necessity Independent Medical Review. The physician …”
And one the reviewer upheld
“The parent of an 8-year-old female enrollee has requested testing for central auditory processing disorders (CAPD) for evaluation of the enrollee’s medical condition. Findings: The physician reviewer found the submitted documentation fails to establish the medical necessity for the requested services. The article by Moore notes that CAPD is ill-defined and interventions appear to have limited effectiveness. The author further …”
- 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 Ears/Nose/Throat overturned?
In 8 California IMR decisions from 2002 to 2014, reviewers overturned 1 (12.5%). 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.