Physical Therapy for GU/ Kidney Disorder: 50.0% of denials overturned
In 6 California IMR decisions from 2003 to 2021, reviewers overturned 3 (50.0%). In the last five years: 0.0% of 1. 5 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“The patient has requested authorization and coverage for physical therapy three times per week and occupational therapy three times per week. Without optimization in functional status, this patient is at increased risk of a compromised functional status. Based on the available records, the patient partially improved with physical and occupational therapies. Specifically, the patient’s bed mobility improved from maximum assistance …”
“Physician 1: The patient is a 45-year-old female with a 20-year history of urinary urge incontinence and a more recent history of stress incontinence. She was referred to a physical therapist for treatment of her condition and indicates that progress has been made. The patient has requested reimbursement for physical therapy with biofeedback and the purchase of a pelvic floor …”
“A 54-year-old female enrollee requested authorization and coverage of a referral to an urologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollee’s bladder control problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plan’s denial on the basis that the requested …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for all or any of the requested twelve physical therapy office visits.Clemens and colleagues state that the pathophysiology of chronic male pelvic pain syndrome is generally poorly understood. While pharmacotherapy, physical therapy, injection therapy and mental health interventions are often employed for treatment of this condition, there is …”
- 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 Physical Therapy denials for GU/ Kidney Disorder overturned?
In 6 California IMR decisions from 2003 to 2021, reviewers overturned 3 (50.0%). In the last five years: 0.0% of 1. 5 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.