Radiation Oncology for Cancer: 39.2% of denials overturned
In 148 California IMR decisions from 2003 to 2015, reviewers overturned 58 (39.2%). 49 were medical-necessity disputes, 98 experimental/investigational, 1 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 29 | 37.9% | 39.2% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 12 | 41.7% | 39.2% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 10 | 50.0% | 39.2% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 0.0% | 39.2% |
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 65-year-old female enrollee requested services on an emergent or urgent basis for medical treatment of her metastatic neuroendocrine tumor with carcinoid syndrome. Findings: The physician reviewer found that the submitted clinical documentation demonstrates that the patient’s decision to seek care in Switzerland was consistent with the actions of a prudent layperson in this setting. Although the patient's medical condition …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested intensity modulated radiation therapy for treatment of his medical condition. Three physician reviewers found that because surgery for cervical esophageal cancer would require a pharyngo-laryngo-esophagectomy, chemoradiation is the treatment of choice. The intensity modulated radiation therapy technique allows the optimization of target volume coverage while allowing reduction of the dose to …”
“A 50-year-old male enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of his stage IV colon cancer. Findings: Three physician reviewers found that current guidelines state that patients with oligometastatic colon cancer should be treated aggressively including local treatment to each liver lesion in the form of surgery or radiation (Benson, et al). The records indicate that this patient …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested brachytherapy for treatment of her basal cell carcinoma on the face. The physician reviewer found that basal cell carcinoma is the most common form of non-melanoma skin cancers in the Caucasian population representing approximately 75%. The standard of care for basal cell carcinoma is typically local destruction or surgical removal, including …”
- 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 Radiation Oncology denials for Cancer overturned?
In 148 California IMR decisions from 2003 to 2015, reviewers overturned 58 (39.2%). 49 were medical-necessity disputes, 98 experimental/investigational, 1 urgent care.
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.