Skill Nsg Vsts for Pediatrics: 85.7% of denials overturned
In 7 California IMR decisions from 2011 to 2021, reviewers overturned 6 (85.7%). In the last five years: 0.0% of 1. 7 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for in-home private during nursing home services. Kuo and colleagues noted that the parents of medically complex children with special health care needs spend an average of nearly nine hours per day managing the patient’s basic healthcare needs, such as personal hygiene and feeding, administering drugs and …”
“Nature of Statutory Criteria/Case Summary: The enrollee’s parent has requested authorization and reimbursement for pediatric day health care and private duty nursing/nursing care at home. The record indicates the enrollee is diagnosed with Koolen de Vries Syndrome after genetic testing was done and revealed KANLS1 mutation. The enrollee had been feeding poorly after delivery and magnetic resonance imaging (MRI) of …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for in-home nursing services up to 12 hours per day. Home health care aims to provide patients with chronic conditions comprehensive health care within a nurturing home environment. Providers are tasked with maximizing the capabilities of the patient and minimizing the effects of the disabilities. Children with …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for continued in-home private duty nursing services for 86 hours per week. Home based nursing services are essential for the parents of young patients with life-limiting or life-threatening diseases who spend an average of nearly nine hours per day managing the patient’s basic healthcare needs such as …”
- 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 Pediatrics overturned?
In 7 California IMR decisions from 2011 to 2021, reviewers overturned 6 (85.7%). 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.