Hemorrhoids denials in California external review
In the California DMHC record, independent physician reviewers decided 12 published external-review cases involving hemorrhoidsand overturned the plan’s denial in 8.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 6 | 0% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 4 | 25% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization for treatment of the enrollee who has a history of hemorrhoids. Findings: 2/3 of the physician reviewers found that THD is a technique used by colorectal surgeons as a treatment option for hemorrhoids. Multiple studies in support of THD have been recently published. For example, a recent systematic review and meta-analysis was published regarding the clinical outcomes and effectiveness of surgical treatments for hemorrhoids. The review included 98 studies with 11 treatments for hemorrhoids and 7,827 patients. The authors concluded that THD was associated with less postoperative bleeding and therefore, less emergency reoperations as well as decreased postoperative complications, shorter operative time, and decreased pain.
Where the denial was upheld
Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for hydrocortisone acetate suppositories. Findings: The physician reviewer found that the enrollee has hemorrhoids and at an office visit reported a two year history of intermittent blood in his stool that is minimal, occurs once a week and is pinkish in color. He refused a rectal exam. His provider prescribed Proctosol HC cream, and upon enrollee request, referred him to a gastroenterology (GI) specialist. On a follow-up visit, the enrollee indicated his hemorrhoids are getting better after using the cream, but also requested a suppository for his hemorrhoids.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nifedipine 0.2% ointment for treatment of the enrollee’s hemorrhoids and anal fissure. Findings: The physician reviewer found that the request for nifedipine 0.2% ointment is not medically necessary for treatment of the patient’s medical condition. An anal fissure is a tear in the skin of the lower half of the anal canal, often with accompanying severe and sharp pain, irritation and tenderness. Sphincterotomy remains the gold standard, but it may lead to incontinence in some patients. Rectiv (nitroglycerin) and various calcium channel blocker therapies have been tested with varying outcomes. The study by colleagues compared the effect of the addition of oral and topical nifedipine to conservative measures in the treatment of fissure-in-ano.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving hemorrhoids, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY