Walker for CNS/ Neuromusc Dis: 61.5% of denials overturned
In 13 California IMR decisions from 2003 to 2020, reviewers overturned 8 (61.5%). 8 were medical-necessity disputes, 5 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. | 5 | 20.0% | 61.5% |
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: The parent of an enrollee has requested authorization and coverage for a walker with seat and pelvic support. Findings: The physician reviewer found that, as is, the goal with all treatment for cerebral palsy, surgery aims to provide children the greatest chance of living as independently as possible. This patient has been in a power …”
“The parent of a seven-year-old enrollee has requested a crocodile gait trainer for medical treatment of the enrollee’s hypotonia and myoclonus. Findings: The physician reviewer found that as the documentation indicated, the patient would be utilizing this assistive gait trainer to be more independent and participate more effectively in the school environment. Without this device, the patient is confined to …”
“A 57-year-old female enrollee requested the WalkAide functional electrical stimulator (FES) for medical treatment of her foot drop secondary to multiple sclerosis. Findings: Three physician reviewers found that in this patient’s situation, she has documented foot drop secondary to multiple sclerosis. In the past, she has failed a trial of an AFO with over 100 falls. Given the provided literature …”
And one the reviewer upheld
“An enrollee has requested authorization and coverage for a ReWalk personal system. The published evidence indicates that powered exoskeletal devices aimed at enabling upright ambulation in patients with paraplegia are not an efficient, reliable or practical means of mobility for this patient population. Further, there are multiple risks associated with the use of these devices as mobility devices outside of …”
- 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 Walker denials for CNS/ Neuromusc Dis overturned?
In 13 California IMR decisions from 2003 to 2020, reviewers overturned 8 (61.5%). 8 were medical-necessity disputes, 5 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.