Walker for Orth/Musculoskeletal: 50.0% of denials overturned
In 8 California IMR decisions from 2007 to 2019, reviewers overturned 4 (50.0%). 6 were medical-necessity disputes, 2 experimental/investigational.
What the findings mention
From recent overturned decisions
“A 58-year-old male has requested neuromuscular electrical stimulation with a WalkAide device for treatment of hisspa stic paraplegia. Findings: The physician reviewer found that there is limited research on the benefits of functional electrical stimulation (FES) over use of a standard AFO for foot drop. In a small clinical trial, FES was shown to improve symmetry and speed of gait …”
“A 48-year-old male has requested a WalkAide functional electrical stimulator (FES) for treatment of his foot drop status post cerebral vascular accident (CVA). Findings: The physician reviewer found that the patient is is reported to have residual hemiparesis since a prior stroke, with foot drop for the last 21 years. He has a mechanical heart valve due to prior endocarditis …”
“A 38-year-old male has requested electrical muscle treatment (WalkAide) for treatment of his right-sided weakness, spasticity and incoordination. Findings: The physician reviewer found that the patient suffered multiple injuries in a motorcycle accident. The medical records noted a cervical spine injury. As a result, the patient has spasticity of his leg and arm and right-sided hemiparesis, including a foot drop. …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an UPWalker. A review of the literature does not reveal that the requested UPWalker is medically necessary for this patient. The physical examination did demonstrated that the patient is able to complete her mobility-related activities of daily living with her current assistive device. The records do not …”
- 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 Orth/Musculoskeletal overturned?
In 8 California IMR decisions from 2007 to 2019, reviewers overturned 4 (50.0%). 6 were medical-necessity disputes, 2 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.