OON Referral for Immuno Disorders: 22.2% of denials overturned
In 9 California IMR decisions from 2006 to 2020, reviewers overturned 2 (22.2%). 8 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 0.0% | 22.2% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 0.0% | 22.2% |
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 consultation with an endocrinologist that provides tertiary level of care. Findings: The physician reviewer found that Miguel and colleagues describe Graves’ ophthalmopathy (GO) as an autoimmune disorder and the most frequent extrathyroidal manifestation of Graves’ disease that, despite recent progress in the understanding of its pathogenesis, …”
“A forty-four year-old male with a diagnosis of chronic fatigue syndrome is requesting authorization an out-of-network referral. Reviewer’s Findings: The reviewing physician found that because of the complexity of the patient’s case an outside referral is appropriate. The Health Plan denial was overturned.”
And one the reviewer upheld
“The enrollee is requesting authorization and coverage for the treatment plan by provider, to include the medications: Valtrex (valacyclovir) 500mg three (3) times daily, Abilify (aripiprazole) 1.5mg daily, low-dose naltrexone 4.5mg daily, and Plaquenil (hydroxychloroquine) 300mg daily. The enrollee has chronic fatigue syndrome/myalgic encephalomyelitis/systemic exertion intolerance disease. She complains of profound fatigue, un-improved with bed rest and worsened by physical …”
- 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 Immuno Disorders overturned?
In 9 California IMR decisions from 2006 to 2020, reviewers overturned 2 (22.2%). 8 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.