Septoplasty for Respiratory System: 50.0% of denials overturned
In 8 California IMR decisions from 2002 to 2017, reviewers overturned 4 (50.0%). 8 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 50.0% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“A 57-year-old female enrollee has requested endoscopy sinus surgery (septoplasty/SMR/maxillary crest reconstruction, bilateral concha bullosa reconstruction with limited ethmoidectomy with possible balloon sinusotomy of the maxillary sinus) for treatment of her obstructive sleep apnea. Findings: The physician reviewer found that the submitted documentation demonstrates the patient presents with the primary problem of sleep apnea and nasal obstruction. Based on the …”
“A 54-year-old female enrollee has requested for nasal surgery (septoplasty and turbinectomy) and uvulopalatopharyngoplasty (UPPP) for treatment of her nasal obstruction and/or obstructive sleep apnea. Findings: The physician reviewer found that UPPP is indicated for patients with significant sleep apnea who have failed CPAP. Significant sleep apnea is defined as a respiratory disturbance index over 15 or a lower index …”
“The parent of a ten year-old female with chronic nasal congestion is requesting authorization of a septoplasty. The patient has leftward deviation of the anterior portion of the nasal septum causing narrowing of the anterior portion of the left nasal cavity. The patient has tried multiple allergy medications and topical steroid sprays without relief.Reviewer’s Findings:The reviewing physician found that the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An 18-year-old female enrollee has requested authorization and coverage for septoplasty (CPT code 30520), inferior turbinate reduction (CPT code 30140), and open nasal reconstruction (CPT code 30410). Findings: The physician reviewer found that According to the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF), indications for septoplasty and turbinate reduction surgery include nasal obstruction …”
- 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 Septoplasty denials for Respiratory System overturned?
In 8 California IMR decisions from 2002 to 2017, reviewers overturned 4 (50.0%). 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.