Prosthesis for Cardiac/Circ Problem: 50.0% of denials overturned
In 6 California IMR decisions from 2018 to 2024, reviewers overturned 3 (50.0%). In the last five years: 33.3% of 3. 1 were medical-necessity disputes, 5 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 0.0% |
| 2024 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom, myoelectric upper extremity orthosis. In a pilot study of 13 patients with chronic arm weakness from stroke or traumatic brain injury (TBI) treated with a myoelectric orthosis, researchers reported that motor learning-based therapy resulted in clinically significant gains. In a three-month observational study evaluating 18 patients …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a left thumb prothesis.Findings: Two physician reviewers found that there is sufficient support for the requested device in this patient’s case. The records document that the patient is post-amputation. The thumb affects 40% of hand function, and any type of device should afford length, stability, and opposition. …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a right leg lower limb replacement prosthetic. In this case, there is evidence of need for prosthetic socket adjustment and replacement of the patient’s foot component. The records do not include documentation that the socket, couple or shank need to be replaced. Given these findings, a new …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a MyoPro Motion G orthotic device. There is a lack of evidence in current medical literature supporting the use of the requested device following a cerebral event, such as stroke, in assisting a patient with regaining neurological or muscular strength or function, such as the innate ability …”
- 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 Cardiac/Circ Problem overturned?
In 6 California IMR decisions from 2018 to 2024, reviewers overturned 3 (50.0%). In the last five years: 33.3% of 3. 1 were medical-necessity disputes, 5 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.