Ketamine Infusion denials in California external review
In the California DMHC record, independent physician reviewers decided 29 published external-review cases involving Ketamine Infusionand overturned the plan’s denial in 31%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Complex Regional Pain Syndrome | 17 | 29.4% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 20 | 25% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 9 | 44.4% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient Ketamine infusion, continuous for five to seven days. Ketamine infusions are an effective treatment option for complex regional pain syndrome (CRPS) that is refractory to standard treatments such as medications, sympathetic nerve blocks, therapy, and multidisciplinary care. Researchers report that in a systematic review, 13 of 14 studies reviewed found that Ketamine infusions resulted in a decrease in pain scores and relief of symptoms.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient Ketamine infusion, continuous for five to seven days. Ketamine infusions are an effective treatment option for complex regional pain syndrome (CRPS) that is refractory to standard treatments such as medications, sympathetic nerve blocks, therapy, and multidisciplinary care. One study found that Ketamine infusions resulted in a decrease in pain scores and relief of symptoms. Similarly, another study found that Ketamine treatment led to a decreased mean pain score in comparison to the self-controlled baseline and that Ketamine infusions could provide clinically effective pain relief in the short-term for less than three months.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a series of Ketamine infusions. The records reflect that this patient has a history of complex regional pain syndrome (CRPS) which has been refractory to medication management, acupuncture, chiropractic care, and interventional procedures. In a meta-analysis of the current medical literature regarding the effects of Ketamine infusion for treating CRPS, authors found that Ketamine treatment led to a decreased mean pain score in comparison to the self-controlled baseline. However, the authors further noted, “Our findings suggested that Ketamine infusion can provide clinically effective pain relief in short term for less than three months.
ature of Statutory Criteria/Case Summary: The patient is a 53-year-old female diagnosed with complex regional pain syndrome (CRPS) involving the left foot. Findings: The physician reviewer found that the patient underwent left gastrocnemius tendon recession, left foot subtalar arthrodesis, left first ray bunionectomy, left fifth toe hammer toe surgery, and left navicular resection with tendon interposition. A report dated 1/31/19 noted that the patient developed compartment syndrome a few days after the surgery and was treated in the emergency department and discharged. When her cast was removed, she developed severe post-operative pain, sensitivity to cold, touch, numbness, and inability to bear weight on the left foot that gradually worsened to the extent that she was unable to walk.
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 treatment 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 Ketamine Infusion, 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