SCP Consult Refer for Infectious Disease: 28.6% of denials overturned
In 7 California IMR decisions from 2002 to 2023, reviewers overturned 2 (28.6%). In the last five years: 50.0% of 2. 7 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
| 2023 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Freestyle Libre continuous glucose monitor (CGM) system. The records provided for review document that this patient has a history of type 2 diabetes. The patient’s provider has recommended treatment with a Freestyle Libre CGM, given the patient’s suboptimal control of diabetes, which …”
“Nature of Statutory Criteria/Case Summary: A 37-year-old female enrollee has requested authorization and coverage for a consultation with a podiatrist. Review of criteria indicates that a referral is medically necessary when the nail requires further testing and that the patient has failed systemic medications. Due to the risks and complications of the systemic medications, the nail condition requires further testing …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for appointment with an infectious disease specialist. Findings: The physician reviewer found that Moriarty and colleagues describe delusional infestation as a psychiatric condition defined by a fixed belief of infestation despite contrary evidence. In this case, given that the patient reports being infested with a variety of parasites …”
- 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 Infectious Disease overturned?
In 7 California IMR decisions from 2002 to 2023, reviewers overturned 2 (28.6%). In the last five years: 50.0% of 2. 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.