SCP Consult Refer for Foot Disorder: 100.0% of denials overturned
In 7 California IMR decisions from 2004 to 2019, reviewers overturned 7 (100.0%). 7 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“The patient has requested authorization and coverage for treatment by a podiatrist. After careful review of the enclosed information and the pertinent guidelines for this case, the patient should receive at least one visit with a podiatrist for a comprehensive foot evaluation. Documentation enclosed in this case advised that the patient is a type I diabetic with hyperglycemia. Absent in …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation and office visit with a podiatrist. Findings: The physician reviewer found that submitted documentation supports the medical necessity of the requested services. This patient reported left foot pain status post motor vehicle accident. The records indicated that his foot pain was affecting his ability to …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested podiatry consultation with Hermoz Ayvazian, DPM for wart removal for treatment of the enrollee’s plantar wart. Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The records document warts to the plantar aspect of the left foot. In his application for independent medical …”
- 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 Foot Disorder overturned?
In 7 California IMR decisions from 2004 to 2019, reviewers overturned 7 (100.0%). 7 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.