OON Referral for OB-GYN/ Pregnancy: 28.6% of denials overturned
In 7 California IMR decisions from 2003 to 2018, reviewers overturned 2 (28.6%). 7 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for urogynecologist consultation. The submitted documentation supports the medical necessity of the requested services. This patient presents with mild symptoms consistent with pelvic floor weakness and prolapse. Her clinical presentation is not one typically seen with this disease. She does not have typical risk factors for prolapse. In …”
“A 34-year-old female enrollee has requested for a follow-up visit and perinatology (detailed fetal anatomy) ultrasound for evaluation of her high-risk pregnancy. Findings: The physician reviewer found that uterine fibroids can lead to pregnancy complications including IVGR, abortion and pre-term labor. Perinatology ultrasound is sometimes necessary in cases such as this to monitor fetal growth, fibroid growth, and sometimes other …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested treatment with an integrative medicine specialist and acupuncture for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has chronic medical problems. There is a lack of evidence indicating that an integrative medicine specialist …”
- 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 OB-GYN/ Pregnancy overturned?
In 7 California IMR decisions from 2003 to 2018, reviewers overturned 2 (28.6%). 7 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.