Req 2nd Opin/OON for Orth/Musculoskeletal: 50.0% of denials overturned
In 6 California IMR decisions from 2010 to 2018, reviewers overturned 3 (50.0%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment with an anatomic and clinical pathologist. Findings: The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. Cysts or tumors of the jaws may present in a variety of ways. One way tumors are identified is …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intrathecal baclofen pump trial for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that the patient has a history of cervical myelopathy. The patient underwent resection of a hemangioblastoma as described above. The patient does not have physical examination findings of spasticity. The patient …”
“A 59-year-old female enrollee has requested an additional medical opinion for treatment of her hip pain. Findings: The physician reviewer found that hip replacement surgery is generally an effective and successful procedure, but aseptic loosening requiring revision occurs at a rate of approximately 1% per year, with pain as the presenting symptom. Other causes of pain, such as infection, also …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee replacement surgery. This patient’s evaluation revealed chondromalacia of patella but no degenerative changes in the medial or lateral compartments. The menisci are also intact. The requested surgical procedure of a total knee replacement surgery necessitates presence of severe degenerative arthritis in at least one compartment, …”
- 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 Req 2nd Opin/OON denials for Orth/Musculoskeletal overturned?
In 6 California IMR decisions from 2010 to 2018, reviewers overturned 3 (50.0%). 6 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.