Physical Therapy for OB-GYN/ Pregnancy: 44.4% of denials overturned
In 9 California IMR decisions from 2004 to 2017, reviewers overturned 4 (44.4%). 9 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 40.0% | 44.4% |
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 48-year-old female enrollee has requested physical therapy for treatment of her pelvic pain. Findings: The physician reviewer found that there is extensive literature support for physical therapy a treatment for dyspareunia, vulvar pain syndromes, and certain types of pelvic pain. Kotarinos provided an extensive discussion regarding physical therapy for myofascial pelvic pain syndrome, which this patient demonstrated. The author …”
“A 28-year-old female enrollee has requested medical services for the treatment of her rectal evacuation pelvic floor disorder. Findings: The physician reviewer found that chronic pelvic pain and gastrointestinal dysfunction can lead to dysfunction and dysynergia of the pelvic floor muscles. Pelvic floor dysfunction can likewise lead to pain and worsening gastrointestinal dysfunction. Pelvic floor PT has been shown to …”
“A fifty year-old female who has had a history of chronic pelvic pain is seeking reimbursement for the previous physical therapy as well as authorization for additional therapy. Reviewer’s Findings: The reviewing physician found that there is adequate scientific evidence demonstrating the benefit of utilizing physical therapy to treat certain types of chronic pelvic pain. The reviewing physician found that …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy twice per week. Findings: The physician reviewer found that the request for authorization and coverage for physical therapy twice per week is not medically necessary for treatment of this patient’s symptoms. The documentation indicates that the patient has been evaluated by physical medicine and rehabilitation, …”
- 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 OB-GYN/ Pregnancy overturned?
In 9 California IMR decisions from 2004 to 2017, reviewers overturned 4 (44.4%). 9 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.