Lab Work denials in California external review
In the California DMHC record, independent physician reviewers decided 1,017 published external-review cases involving Lab Workand overturned the plan’s denial in 31.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Lab Work denials
| Category | Decisions | Overturned |
|---|---|---|
| Crohns Disease | 55 | 18.2% |
| Skin | 54 | 5.6% |
| Pregnancy | 52 | 28.8% |
| Thyroid Problems | 44 | 65.9% |
| Breast | 43 | 60.5% |
| Lung | 42 | 76.2% |
| Ulcerative Colitis | 23 | 21.7% |
| Prostate | 23 | 21.7% |
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. | 899 | 31.9% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 115 | 28.7% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 3 | 33.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) exposure and response (ERP) therapy, (2) GeneSite blood testing, (3) single-photon emission computed tomography (SPECT) brain scan, and/or (4) transcranial magnetic stimulation (TMS). Findings: The physician reviewer found that (APA) recommends ERP therapy as a first-line treatment of OCD, even for patients with developmental delay. In this clinical setting, the requested ERP therapy is medically indicated for treatment of the patient’s intrusive urges, obsessions and compulsions, and suicidal and homicidal ideations stemming from his OCD. In this patient’s case, ERP therapy is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, ERP therapy is clinically appropriate in terms of type, frequency, extent, site, and duration.
Physician 1: The patient is a 55-year-old woman diagnosed with breast cancer in September 2004. At that time she was found to have a 1.5 cm poorly differentiated invasive ductal adenocarcinoma with four sentinel nodes being negative. The estrogen and progesterone receptors were positive, and HER2 was negative. To aid in making the decision as to the usefulness of adjuvant chemotherapy, an Oncotype analysis was performed. This revealed a “recurrence score” that predicted a 27% chance of recurrence of the patient’s cancer. Because of the high predicted risk of recurrence, the patient accepted the need for adjuvant chemotherapy.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methicillin-resistant staphylococcus aureus (MRSA) assessment, neurology assessment, magnetic resonance imaging (MRI) scan, Ross Information Processing Assessment, Second Edition (RIPA-2) testing, and daily physical therapy. Findings: The physician reviewer found that with regards to the request for MRSA assessment, active surveillance consists of performing screening cultures (of the nares, oropharynx, and/or perineum) to identify asymptomatic patients who are colonized with antibiotic-resistant bacteria. This is typically performed in a hospital with the goal of prevention of spread of MRSA to other patients. Active surveillance cultures appear to be most useful in the setting of hospital outbreaks and among patients at high risk for MRSA carriage.
Nature of Statutory Criteria/Case Summary: The patient presented for a cardiovascular risk assessment evaluation secondary to a diagnosis of dyslipidemia. The most recent cholesterol level is 209, with low density lipoprotein (LDL) of 114 and high density lipoprotein (HDL) of 78. The patient denied associated symptoms, including decreased activity or exercise tolerance, shortness of breath, swelling, or chest pain. There was no documented history of hypertension or diabetes. The patient was educated and following a low carbohydrate, low fat diet, and exercising five to six times per week. She was referred for advanced lipoprotein testing including lipid particle number and sizing for further risk stratification.
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 Lab Work, 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