Radiofreq Ablat for OB-GYN/ Pregnancy: 7.1% of denials overturned
In 14 California IMR decisions from 2006 to 2018, reviewers overturned 1 (7.1%). 2 were medical-necessity disputes, 12 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 8 | 0.0% | 7.1% |
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
“The patient is a 59-year-old female with a history of chronic pelvic pain. Her perivaginal pain has been evaluated and treated extensively. Both conservative therapies such as medications and physical therapy and interventional procedures such as surgical release of the pudendal nerves and Botox injections have proven to be unsuccessful. The patient continues with pain and paresthesias in the clitoris, …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A 54-year-old female enrollee has requested authorization and coverage for radiofrequency ablation. Findings: The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) has weighed in on both the surgical and alternative conservative management options of uterine leiomyomas. Treatment options include myomectomy or hysterectomy, uterine artery embolization (UAE), radiofrequency ablation, or a …”
- 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 Radiofreq Ablat denials for OB-GYN/ Pregnancy overturned?
In 14 California IMR decisions from 2006 to 2018, reviewers overturned 1 (7.1%). 2 were medical-necessity disputes, 12 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.