Organ Transplant for GU/ Kidney Disorder: 50.0% of denials overturned
In 10 California IMR decisions from 2002 to 2023, reviewers overturned 5 (50.0%). In the last five years: 50.0% of 2. 8 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2023 | 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 | 75.0% | 50.0% |
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 immediate referral for a liver transplant. Early liver transplant in the setting of decompensated alcoholic liver disease, defined as before six months of abstinence from alcohol, is recommended for carefully selected patients with severe medically refractory alcohol associated liver disease who are considered to be at low …”
“A 50-year-old female enrollee requested evaluation at a medical transplantation center for medical treatment of the enrollee’s end-stage renal disease. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Per the medical evidence, there is a survival superiority of kidney transplant compared to dialysis. The records indicate a significantly shortened waiting time …”
“A 50-year-old female enrollee has requested steroid-free protocol as part of her kidney transplant surgery for treatment of her chronic kidney disease. Findings: The physician reviewer found that one of the major risks of renal transplant is the possibility of rejection of the transplanted kidney. Current therapeutic protocols for kidney transplant patients have markedly reduced the incidence of acute rejection. …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for platelet rich plasma. In gynecology, the research on platelet rich plasma therapy is very limited and primarily anecdotal. A recent publication presents a comprehensive review of the use of platelet rich plasma in various gynecologic applications including treatment for refractory endometrium, Asherman's syndrome, poor …”
- 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 Organ Transplant denials for GU/ Kidney Disorder overturned?
In 10 California IMR decisions from 2002 to 2023, reviewers overturned 5 (50.0%). In the last five years: 50.0% of 2. 8 were medical-necessity disputes, 2 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.