Stem Cell Transplant for Immuno Disorders: 85.7% of denials overturned
In 7 California IMR decisions from 2002 to 2016, reviewers overturned 6 (85.7%). 1 were medical-necessity disputes, 6 experimental/investigational.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for evaluation for autologous systemic immune suppression trial #NCT01445821 for evaluation of the enrollee’s scleroderma. Findings: The physician reviewer found that when patients with advanced cancers have exhausted standard regimens, the National Cancer Institute Physician’s Data Query recommends enrollment in a clinical trial. In this case, the patient …”
“A 49-year-old female enrollee has requested participation in the autologous stem cell transplant randomized SCOT clinical trial for treatment of her systemic sclerosis. Findings: Two physician reviewers found that this patient has debilitating and progressive scleroderma that is recalcitrant to basic approved therapies. She has been on immunosuppressives such as azathioprine, methotrexate and steroids, although her disease has been progressive, …”
“The parent of a 14-year-old female enrollee has requested a stem cell transplant evaluation for treatment of the enrollee’s systemic scleroderma. Findings: Three physician reviewers found that this patient has rapidly progressive systemic sclerosis with diffuse skin involvement, gastrointestinal involvement and pulmonary involvement. The skin and internal organ involvement rapidly progressed in less than one year. Currently, there is no …”
And one the reviewer upheld
“A 43-year-old female enrollee has requested a phase I clinical trial of high dose immunoablation followed by autologous stem cell transplantation (NU FDA CIDP.AUTO 2003) for the treatment of her chronic inflammatory demyelinating polyneuropathy. Findings: Three physician reviewers found that although immunoablation followed by stem cell transplantation shows promise as a potential therapy for chronic inflammatory demyelinating polyneuropathy, there currently …”
- 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 Immuno Disorders overturned?
In 7 California IMR decisions from 2002 to 2016, reviewers overturned 6 (85.7%). 1 were medical-necessity disputes, 6 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.