Tx for Allergies for Respiratory System: 61.8% of denials overturned
In 34 California IMR decisions from 2002 to 2018, reviewers overturned 21 (61.8%). 34 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 66.7% | 61.8% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 16.7% | 61.8% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 5 | 80.0% | 61.8% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epinephrine auto injector. Findings: The physician reviewer found that candidates for immunotherapy are patients whose symptoms are not controlled adequately by medication and avoidance. The allergy immunotherapy practice parameter recommends that at the onset of immunotherapy, patients should be counseled on the possibility of immediate and delayed …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pollen and allergy injections performed weekly for treatment of the enrollee’s allergic rhinitis and asthma. Findings: The physician reviewer found that based on the available documentation, the service of immunotherapy dosed at once weekly intervals meets the current criteria for medical necessity and is …”
“The parent of a female enrollee requested Singulair (montelukast) for treatment of her allergic rhinitis. Findings: The physician reviewer found that the patient has a history of allergic rhinitis, hypothyroidism and hives and has failed oral antihistamines. Given that this patient also has a history of hives and hypothyroidism, it is medically reasonable and appropriate to use the montelukast to …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly allergy/immunotherapy injections (CPT codes 95117 and 95144). The submitted documentation fails to demonstrate the medical necessity of the requested services. Allergy shots are indicated for persistent symptoms on a seasonal and/or perennial basis for patients with an inadequate or partial response to environmental control and medications. …”
- 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 Tx for Allergies denials for Respiratory System overturned?
In 34 California IMR decisions from 2002 to 2018, reviewers overturned 21 (61.8%). 34 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.