Skill Nsg Vsts for Digestive System/ GI: 40.0% of denials overturned
In 5 California IMR decisions from 2002 to 2016, reviewers overturned 2 (40.0%). 5 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested in-home private duty nursing services for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that according to the American Academy of Pediatrics (AAP) guidelines for home care of infants, children, and adolescents with chronic disease, “the goal of a home health care program for infants, …”
“A 90-year-old female enrollee requested authorization and coverage of skilled nursing care due to gastrostomy tube feedings and decubitus care. The Health Plan denied the enrollee’s request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plan’s denial on the basis that the requested services …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 24 hours or more of licensed vocational nurse (LVN) services a week and one hour per month of registered nurse (RN) supervision for treatment of the enrollee’s achondroplasia, autism, left eye blindness, single kidney, developmental delay, and feeding problem with gastrostomy tube. Findings: The physician reviewer found …”
- 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 Skill Nsg Vsts denials for Digestive System/ GI overturned?
In 5 California IMR decisions from 2002 to 2016, reviewers overturned 2 (40.0%). 5 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.