Prosthesis for Cancer: 60.0% of denials overturned
In 5 California IMR decisions from 2011 to 2024, reviewers overturned 3 (60.0%). In the last five years: 50.0% of 2. 4 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 1 | 100.0% |
| 2024 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that The patient requested authorization and coverage for a Ossur Rheo microprocessor knee and Ottoback Maverick Comfort AT prosthetic foot.Current literature regarding the benefits of microprocessor-aided prosthetic knees relative to prosthetic knees without microprocessor-aided control is largely mixed and based on small patient numbers with low-quality data. A study indicated that there is a lack of …”
“Nature of Statutory Criteria/Case Summary: A 61-year-old female enrollee has requested authorization and coverage for mastectomy bra and prosthesis for left breast. As noted by the American Society of Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve a patient’s appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of …”
“A 63-year-old male enrollee has requested a three piece inflatable penile prosthesis for treatment of his erectile dysfunction. Findings: The physician reviewer found that treatment of erectile dysfunction is goal directed; appropriate therapy is based on what is successful and acceptable to the individual patient. Although erectile dysfunction is often viewed as only a physical dilemma, the individual’s psychological insult …”
And one the reviewer upheld
“The physician reviewer found that coverage for myoelectric orthosis for the right arm. An observational study found that 18 patients with upper extremity hemiparesis after stroke demonstrated significantly reduced impairment while wearing a myoelectric elbow-wrist-hand orthosis. In another study, nine stroke patients using MyoPro for upper limb impairment reported statistically significant improvement in motor control and muscle tone. A third …”
- 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 Prosthesis denials for Cancer overturned?
In 5 California IMR decisions from 2011 to 2024, reviewers overturned 3 (60.0%). In the last five years: 50.0% of 2. 4 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.