TENS Unit for CNS/ Neuromusc Dis: 20.0% of denials overturned
In 5 California IMR decisions from 2006 to 2016, reviewers overturned 1 (20.0%). 2 were medical-necessity disputes, 3 experimental/investigational.
What the findings mention
From recent overturned decisions
“A 27-year-old female enrollee has requested an occipital nerve stimulator trial for treatment of her occipital neuralgia. Findings: The physician reviewer found that the facts probative of the medical necessity of the requested device for this patient include the severity and refractory nature of the headaches, her young age, the duration of symptoms, and disability due to the condition. At …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacral nerve stimulation for treatment of the enrollee’s anal pain and sphincterotomy. Findings: Two physician reviewers found that within the field of colorectal surgery, the primary indication for sacral nerve stimulation is fecal incontinence. There is a lack of significant data supporting the use of sacral nerve …”
- 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 TENS Unit denials for CNS/ Neuromusc Dis overturned?
In 5 California IMR decisions from 2006 to 2016, reviewers overturned 1 (20.0%). 2 were medical-necessity disputes, 3 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.