Shoe Inserts for Orth/Musculoskeletal: 66.7% of denials overturned
In 9 California IMR decisions from 2015 to 2020, reviewers overturned 6 (66.7%). 9 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 50.0% | 66.7% |
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
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral custom foot orthotics. The submitted documentation supports the medical necessity of the requested equipment. The records document foot pain, metatarsalgia, a painful tailor’s bunion, and flat feet/pes planovalgus. The patient’s provider has recommended a pair of custom foot orthotics. Custom foot orthotics are utilized to support …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left shoe orthotics. Studies indicate that limb length discrepancies more than 2.0 cm are frequently problematic and hip and knee pathology is present in an increased number of patients with limb length discrepancies over 0.5 cm. In addition, low back problems are reportedly common on same side …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom molded shoe inserts. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollee’s pain. At issue in this case is whether the requested equipment, custom molded shoe inserts, is medically necessary for treatment of the …”
And one the reviewer upheld
“Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for foot orthotics. At a podiatry visit, the enrollee reported her problem started when she rolled her right ankle and broke her fifth metatarsal bone. The podiatry assessment indicates chronic right ankle instability secondary to malunion fracture of the fifth metatarsal, creating right foot varus, peroneal tendinopathy right, peroneal …”
- 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 Shoe Inserts denials for Orth/Musculoskeletal overturned?
In 9 California IMR decisions from 2015 to 2020, reviewers overturned 6 (66.7%). 9 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.