Stem Cell Transplant for Cancer: 44.4% of denials overturned
In 18 California IMR decisions from 2002 to 2014, reviewers overturned 8 (44.4%). 3 were medical-necessity disputes, 15 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 10 | 50.0% | 44.4% |
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 64-year-old female enrollee has requested allogeneic hematopoietic stem cell transplantation for treatment of her multiple myeloma. Findings: Two physician reviewers found that allogeneic stem cell transplant may be the most reasonable treatment option for patients with multiple myeloma who have not responded to autologous transplants and chemotherapy. In such a clinical situation, the medical literature supports the use of …”
“A 59-year-old male enrollee has requested allogeneic bone marrow transplant for the treatment of his chronic lymphocytic leukemia. Findings: Two physician reviewers found that this patient has high-risk chronic lymphocytic leukemia (CLL). He has poor prognosis molecular features (CD38 positivity) and high-risk clinical features including lymphocyte count greater than 200,000, rapid lymphocyte doubling time, and short response to initial therapy. …”
“A 49-year-old female enrollee has requested participation in a Phase III stem cell transplantation trial at the University of Arkansas for treatment of multiple myeloma. Findings: The physician reviewer found that Autologous peripheral stem cell transplant is considered a standard treatment approach to myeloma that has progressed after induction therapy. This approach is endorsed by NCCN guidelines. There is no …”
And one the reviewer upheld
“The parent of a 15-year-old female enrollee has requested zone 1 evaluation of autologous hematopoietic stem cell transplant and stem cell harvest and storage for treatment of the enrollee’s osteosarcoma. Findings: Two physician reviewers found that the patient has apparent progressive disease despite frontline chemotherapy. Given the location of the lesions, she cannot undergo surgery for local control. There is …”
- 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 Stem Cell Transplant denials for Cancer overturned?
In 18 California IMR decisions from 2002 to 2014, reviewers overturned 8 (44.4%). 3 were medical-necessity disputes, 15 experimental/investigational.
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.