Vein Stripping denials: 23.1% overturned by independent reviewers
In 26 California IMR decisions from 2002 to 2022, reviewers overturned the plan 6 times (23.1%). In the last five years: 0.0% of 1. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Cardiac/Circ Problem | 25 | 24.0% | 0.0% of 1 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 0.0% | 23.1% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 25.0% | 23.1% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 33.3% | 23.1% |
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 48-year-old female enrollee requested endovenous laser ablation (CPT code 36478 x 2 for both greater saphenous veins) for medical treatment of the enrollee’s varicose veins. Findings: Two physician reviewers found that review of the submitted documentation and relevant literature supports the requested services in this clinical setting. The patient has significant long-standing symptoms and a CEAP classification of level …”
“A 33-year-old female enrollee has requested chemical treatment of varicose veins for treatment of her chronic venous disease, class 2. Findings: Three physician reviewers found that in this patient’s case, the requested services are likely to be more efficacious than other treatment options. The peer-reviewed medical literature supports the use of sclerotherapy in conjunction with endovenous ablation for the treatment …”
“The patient is a 41-year-old female with a prior history of varicose veins with removal, but no history of greater saphenous vein removal. The patient indicates she is now experiencing severe pain due to her varicose veins, which have been refractory to conservative treatment (i.e., stockings). The results of an ultrasound exam show bilateral greater saphenous vein reflux. The patient’s …”
- 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 Vein Stripping denials overturned?
In 26 California IMR decisions from 2002 to 2022, reviewers overturned the plan 6 times (23.1%). In the last five years: 0.0% of 1.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.