SCP Consult Refer for Respiratory System: 71.4% of denials overturned
In 7 California IMR decisions from 2002 to 2024, reviewers overturned 5 (71.4%). In the last five years: 0.0% of 1. 7 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“The patient has requested authorization and coverage for treatment by a pulmonary specialist, a breathing machine and oxygen, cough syrup with codeine, Albuterol solutions for the enrollee’s nebulizer, and Ventolin HFA mg inhaler #18. The records provided for review document that the patient’s complaints include a cough, but there is no notation of other pulmonary complaints. The records report that …”
“A 59-year-old female enrollee has requested for to see a pulmonologist for treatment of her chronic obstructive pulmonary disease. Findings: The physician reviewer found that COPD is often a progressive disease, and even with optimal management, it is anticipated that a patient's lung function will worsen over time. Patients with COPD require frequent monitoring of symptoms and objective measurement of …”
“This is an unusual case of a 28-year-old male with cystic fibrosis who is status post living lobar lung transplantation eight years ago. The transplant was bilateral from a living donor of one lobe each side. Apparently the patient has done well in the interval and is now working. The patient has recently developed an episode of sinusitis. The patient …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for allergist tertiary center care. The submitted documentation does not support the medical necessity of the requested services. An allergist/immunologist, commonly referred to as an allergist, is specially trained to diagnose, treat, and manage allergies, asthma, and immunologic disorders including primary immunodeficiency …”
- 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 Respiratory System overturned?
In 7 California IMR decisions from 2002 to 2024, reviewers overturned 5 (71.4%). In the last five years: 0.0% of 1. 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.