Pain Mgmt Prog for Orth/Musculoskeletal: 42.9% of denials overturned
In 7 California IMR decisions from 2002 to 2015, reviewers overturned 3 (42.9%). 7 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 50.0% | 42.9% |
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
“A 60-year-old female enrollee has requested reimbursement and prospective authorization and coverage for an intrathecal pump and medications. The Health Plan has denied this request indicating that the service at issue was not and is not medically necessary for treatment of the enrollee’s back pain. Findings: The physician reviewer found that the records indicate the patient has been stable for …”
“A 59-year-old male enrollee has requested a pain management consultation for treatment of his pain. Findings: The physician reviewer found that a pain management consultation is medically necessary for proper evaluation and treatment of this patient’s medical condition. Despite previous reports of physical therapy, the patient continues to complain of severe pain that interferes with his daily life activities. According …”
“The patient is a 60-year-old female with a history of neck and shoulder pain, status post cervical fusion in 1995. She has been treated with multiple medical regimens such as non-steroidal anti-inflammatory drugs, cox II inhibitors, muscle relaxants, Lido-derm patches, steroid injections, physical therapy, acupuncture and chiropractic therapy without sustained pain relief. A pain management specialist evaluated the patient in …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested Vicodin for treatment of her medical condition. Findings: The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the requested medication has not been established. The current standard of care for acute onset back pain is conservative therapy treatment to include physical therapy, massage …”
- 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 Mgmt Prog denials for Orth/Musculoskeletal overturned?
In 7 California IMR decisions from 2002 to 2015, reviewers overturned 3 (42.9%). 7 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.