Revision Procedures for Post Surgical Comp: 40.0% of denials overturned
In 5 California IMR decisions from 2007 to 2020, reviewers overturned 2 (40.0%). 5 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“The patient has requested authorization and coverage for scar tissue removal surgery. The patient underwent cosmetic breast augmentation surgery years ago and developed an area of depressed scar that pulls on the underlying tissue when she raises her arm. She reports pain when this occurs. Kumar and Elavarasi stated, “Pain is always subjective, and every individual use this word through …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to revise a deformed, contracted scar, mid abdomen, 15 cm vertical by 20 cm horizontal subcutaneous symmetrically distributed fibrous tissue. Findings: The physician reviewer found that the surgery to revise a deformed, contracted scar, mid abdomen, 15 cm vertical by 20 cm horizontal subcutaneous symmetrically distributed …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pre-surgical electrical stimulation therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s scrotal pain.At issue in this case is whether the requested pre-surgical electrical stimulation therapy is medically necessary for treatment of the enrollee’s …”
- 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 Revision Procedures denials for Post Surgical Comp overturned?
In 5 California IMR decisions from 2007 to 2020, reviewers overturned 2 (40.0%). 5 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.