Tx for Migraine for CNS/ Neuromusc Dis: 46.9% of denials overturned
In 98 California IMR decisions from 2002 to 2019, reviewers overturned 46 (46.9%). 79 were medical-necessity disputes, 19 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 22 | 59.1% | 46.9% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 13 | 53.8% | 46.9% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 13 | 7.7% | 46.9% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 12 | 75.0% | 46.9% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 7 | 42.9% | 46.9% |
| Urgent or emergencyThe findings mention urgency. | 5 | 80.0% | 46.9% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 5 | 40.0% | 46.9% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 3 | 66.7% | 46.9% |
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
“The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg. The submitted documentation supports the medical necessity of the requested medication. Menstrual migraine is defined as migraine without aura that occurs within days -2 and +3 of the menstrual period on at least 2 of 3 consecutive menstrual cycles (where menstruation onset …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for buprenorphine HCL 2 mg (120 tablets in a 30-day period). The Health Plan has denied this request indicating that the medication at issue was not medically necessary. The buprenorphine HCL 2 mg (120 tablets in a 30-day period) provided was medically necessary for treatment of the patient’s medical condition. …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Lyrica for treatment of the enrollee’s chronic daily headache, generalized anxiety disorder, and major depression. Findings: The physician reviewer found that based on the medical records, the patient has a history of debilitating migraine headaches which has significantly impacted his ability to go to …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The American Academy of Neurology 2012 headache guideline, reaffirmed in 2015, provides evidence and recommendations for management of episodic migraine headache prevention that categorizes drugs into five categories, including Level A (highest evidence), Level B (next highest level of evidence), Level C (lowest level of evidence), Level U (evidence against) and Other. Level A includes …”
- 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 Migraine denials for CNS/ Neuromusc Dis overturned?
In 98 California IMR decisions from 2002 to 2019, reviewers overturned 46 (46.9%). 79 were medical-necessity disputes, 19 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.