Orthotics for Orth/Musculoskeletal: 57.1% of denials overturned
In 28 California IMR decisions from 2003 to 2023, reviewers overturned 16 (57.1%). In the last five years: 87.5% of 8. 27 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 5 | 100.0% |
| 2023 | 2 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 12 | 58.3% | 57.1% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 25.0% | 57.1% |
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 bilateral custom foot orthotics. In this case, the records document overpronation of the bilateral feet, lateral impingement syndrome, and metatarsalgia with suspected plantar plate tear. Orthotics are generally used to treat overpronation that causes symptomatic pathology as they keep the subtalar joint in a neutral position, and …”
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a replacement set of custom orthotics. The requested replacement set of custom orthotics is medically reasonable and necessary to treat this patient’s medical condition based on the facts and relevant medical criteria. A review of the patient’s records provides sufficient evidence of a history of painful hallux …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral custom foot orthotics. The available documentation supports that this patient presented to her provider with left foot pain due to sesamoiditis. Fracture was ruled out via x-rays, computed tomography (CT), and magnetic resonance imaging (MRI) studies. The patient’s provider recommended treatment with custom orthotics to offload the forefoot …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computerized knee ankle foot orthosis (HCPCS L2006).Findings: Two out of three physician reviewers found that a computerized knee ankle foot orthosis (HCPCS L2006) is not likely to be more beneficial for you than any available standard therapy.Deems-Dluhy and colleagues concluded, “The microprocessor swing and stance controlled …”
- 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 Orthotics denials for Orth/Musculoskeletal overturned?
In 28 California IMR decisions from 2003 to 2023, reviewers overturned 16 (57.1%). In the last five years: 87.5% of 8. 27 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.