SCP Consult Refer for Ears/Nose/Throat: 50.0% of denials overturned
In 8 California IMR decisions from 2002 to 2021, reviewers overturned 4 (50.0%). In the last five years: 100.0% of 1. 8 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an otolaryngology office visit at a tertiary care facility.At issue is whether the requested referral for an otolaryngology office visit at a tertiary care facility is medically necessary to treat the patient’s condition for any of the following: to prevent disease, disability, and other health conditions or …”
“A parent of a five-year-old female enrollee has requested a referral to an ear, nose and throat (ENT) specialist for evaluation of her tonsillar hypertrophy. Findings: The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested service. Adenotonsillar hypertrophy is not a benign condition. According to Tatlipinar and colleagues, “Patients with adenoid and …”
“A 27-year-old female enrollee requested authorization and coverage of a referral to an otolaryngologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for evaluation and treatment of the enrollee’s deviated septum and associated airway disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plan’s denial on …”
And one the reviewer upheld
“The parent of a 16-year-old female enrollee has requested an evaluation with an out-of-network audiologist for evaluation of the enrollee’s stated diagnosis of auditory processing deficit. Findings: The physician reviewer found that there is no evidence that the patient has central auditory processing disorder in the submitted documentation. Of note, this patient’s attention deficit/hyperactivity disorder can lead to many symptoms …”
- 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 SCP Consult Refer denials for Ears/Nose/Throat overturned?
In 8 California IMR decisions from 2002 to 2021, reviewers overturned 4 (50.0%). In the last five years: 100.0% of 1. 8 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.