Pain Management for Orth/Musculoskeletal: 37.1% of denials overturned
In 35 California IMR decisions from 2002 to 2018, reviewers overturned 13 (37.1%). 35 were medical-necessity disputes.
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). | 16 | 6.3% | 37.1% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 50.0% | 37.1% |
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: An enrollee has requested authorization and coverage for chiropractic care. There is sufficient support for the requested services in this patient’s case. The records document shoulder pain, neck pain and insomnia. The patient presented to her provider, and she was referred for chiropractic care. Prior x-rays revealed cervical subluxations. Based on the patient’s clinical presentation …”
“A 34-year-old female enrollee has requested chiropractic care for treatment of her sciatica, lumbar spondylosis, and degenerative disc disease. Findings: The physician reviewer found that based on review of the available records, this patient presents with low back and leg pain with MRI evidence of degenerative disc disease and disc bulges. The patient’s degenerative joint disease leads to mechanical and …”
“A 70-year-old male enrollee has requested chiropractic care for treatment of his history of compression fracture of the spine. Findings: The physician reviewer found that based on review of the available records, the requested chiropractic care is medically necessary for treatment of this patient’s medical condition. According to the records, chiropractic treatment has been the only modality to provide him …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested reimbursement for chiropractic services received 9/04/17 through 9/22/17. Upon review of the submitted documentation and relevant literature, the medical necessity of the services at issue is not established. The patient has juvenile idiopathic scoliosis. At present, there is insufficient evidence that the efficacy of non-specific manual …”
- 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 Pain Management denials for Orth/Musculoskeletal overturned?
In 35 California IMR decisions from 2002 to 2018, reviewers overturned 13 (37.1%). 35 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.