Scoping Procedure for Digestive System/ GI: 35.0% of denials overturned
In 20 California IMR decisions from 2002 to 2018, reviewers overturned 7 (35.0%). 8 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. | 4 | 25.0% | 35.0% |
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
“Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested authorization and coverage for a gastrointestinal tract capsule endoscopy of the small bowel. The records document that this patient has had symptoms and elevated calprotectin with normal colonoscopy, suggestive of possible small intestinal Crohn’s disease rather than the current diagnosis of ulcerative colitis. Capsule endoscopy is useful for the …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollee’s Crohn’s disease, ulcer and diarrhea. Findings: The physician reviewers found that current American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohn’s disease. Data from …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy. Findings: Two physician reviewers found that in this case there is a concern that Crohn’s disease is affecting the small intestine and caused the patient’s obstruction. However, Crohn’s disease is one possible cause for obstruction in this case, rather than the established cause. Upper …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wireless capsule endoscopy for gastrointestinal imaging procedure. Findings: Two of the three physician reviewers found per the medical evidence, accepted indications for capsule endoscopy include obscure gastrointestinal bleeding, small bowel Crohn’s disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes, and evaluating the small …”
- 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 Scoping Procedure denials for Digestive System/ GI overturned?
In 20 California IMR decisions from 2002 to 2018, reviewers overturned 7 (35.0%). 8 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.