Pain Medication for Chron Pain Synd: 15.0% of denials overturned
In 20 California IMR decisions from 2017 to 2018, reviewers overturned 3 (15.0%). 17 were medical-necessity disputes, 3 experimental/investigational.
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). | 13 | 0.0% | 15.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 12 | 0.0% | 15.0% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 0.0% | 15.0% |
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: A patient has requested authorization and coverage for Norco, four pills per day. The submitted documentation supports the medical necessity of the requested medication regimen. Per the Centers for Disease Control guidelines, “patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 5-325 mg (one tablet every six hours) for treatment of the enrollee’s ankle pain.Findings: The physician reviewer found that the review of the submitted documentation supports the medical necessity for the request for Norco 5-325 mg (one tablet every six hours). In this case, the patient …”
“Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for oxycodone/acetaminophen for treatment of the enrollee’s chronic back pain. Findings: The physician reviewer found that the records provided for review demonstrate that this patient has tried and failed conservative treatment options including epidural steroid injections for his chronic back pain and sciatica. According to the documents …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has chronic non-malignant pain which was previously treated with opiate analgesia. Clinical practice guidelines do not support restarting opiates for nonmalignant pain, such as chronic low back pain. The long-term outcomes …”
- 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 Chron Pain Synd overturned?
In 20 California IMR decisions from 2017 to 2018, reviewers overturned 3 (15.0%). 17 were medical-necessity disputes, 3 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.