Pain Medication for Cancer: 60.0% of denials overturned
In 5 California IMR decisions from 2019 to 2022, reviewers overturned 3 (60.0%). In the last five years: 66.7% of 3. 5 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2022 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Norco 10/325 tablets, two tablets three times a day (180 tablets per 30 days), (2) Valium 10 mg tablets, one to two tablets every night for sleep and one to two tablets every six hours as needed for anxiety (100 tablets for 30 days), and (3) …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycontin tablet 20 mg CR once every eight hours. Tewes and colleagues state, “The World Health Organization (WHO) recommends a 3-step ladder in which the use of opioids is recommended for moderate and severe cancer pain. If possible, medication should be administered orally and at a specified …”
“The patient has requested authorization and coverage for Norco 10/325 mg, quantity 150, every 30 days. This patient has a history of spinal cord tumor status post resection. The patient’s pain has been managed with Norco. For cancer related pain, opiate pain medications such as Norco have a supported role for pain control. However, Norco 10/325 mg, quantity 300, every …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Lyrica. The records provided for review document that this patient has a history of metastatic breast cancer with bone pain and lumbar radiculopathy. The patient’s pain has been managed with a combination of opioid therapy and brand name Lyrica. The patient has been treated with …”
- 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 Medication denials for Cancer overturned?
In 5 California IMR decisions from 2019 to 2022, reviewers overturned 3 (60.0%). In the last five years: 66.7% of 3. 5 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.