Wheelchair for Pediatrics: 60.0% of denials overturned
In 5 California IMR decisions from 2014 to 2020, reviewers overturned 3 (60.0%). 5 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for a Convaid Cruiser pediatric wheelchair with accessories. The ANSI/RESNA WC19 (WC19) standard specifies design and performance requirements for wheelchairs to be suitable for use in the safe transportation of children. Unlike a non-custom commercial stroller, the Convaid Cruiser pediatric wheelchair fulfills WC19 standards, enabling the patient …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for TiLite titanium wheelchair (or a wheelchair comparable to the same model she has been using). Findings: The physician reviewer found that the patient has a history of spina bifida and is a long term wheelchair user. The patient has developed a gluteal pressure ulcer attributed to the …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a wheelchair for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that the submitted documentation establishes the medical necessity for the requested wheelchair. Lennox-Gastaut syndrome is an epileptic encephalopathy with a diverse set of etiologies, all of which converge on a clinical phenotype that is …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested a wheelchair and related equipment for treatment of her medical condition. The physician reviewer found that the requested services are not medically necessary for treatment of the patient’s medical condition. According to the documentation submitted for review, the patient relies on a wheelchair for mobility and has requested a new wheelchair. …”
- 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 Wheelchair denials for Pediatrics overturned?
In 5 California IMR decisions from 2014 to 2020, reviewers overturned 3 (60.0%). 5 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.