SCP Consult Refer for OB-GYN/ Pregnancy: 81.8% of denials overturned
In 11 California IMR decisions from 2002 to 2018, reviewers overturned 9 (81.8%). 11 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: A 32-year-old female enrollee has requested authorization and coverage for a consultation with a reproductive endocrinologist for evaluation of the enrollee’s endometriosis. Findings: The physician reviewer found that based on the available documentation, it is medically necessary for this patient to be evaluated and treated as considered appropriate by a reproductive endocrinologist. A reproductive endocrinologist …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested an office consultation with a plastic surgeon for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has well-documented signs and symptoms of significant macromastia that has failed reasonable conservative management. She is noted to have …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested a consultation with a fertility specialist for treatment of her possible egg retrieval and use of a surrogate. The physician reviewer found that according to Kuohung and Hornstein, “Age is an important factor affecting a woman’s fertility. The decrease in fecundability with aging is likely due to a decline in both …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested a referral to a Naturopathic physician for treatment of the enrollee’s menopause. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested referral. There are many options for treatment of menopausal symptoms which include hormonal and non-hormonal …”
- 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 OB-GYN/ Pregnancy overturned?
In 11 California IMR decisions from 2002 to 2018, reviewers overturned 9 (81.8%). 11 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.