Specialty Procedures denials in California external review
In the California DMHC record, independent physician reviewers decided 499 published external-review cases involving specialty procedures and overturned the plan’s denial in 35.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By denial reason
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 310 | 34.5% |
| experimental / investigational | 188 | 36.2% |
Within this category
| Subcategory | Decisions | Overturned |
|---|---|---|
| Other | 148 | 40.5% |
| General Anesthesia | 148 | 25.7% |
| Hyperbaric O2 Chamb | 73 | 34.2% |
| Stem Cell Transplant | 56 | 41.1% |
| Organ Transplant | 34 | 50% |
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. | 310 | 34.5% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 188 | 36.2% |
What the reviewers wrote
Where the denial was overturned
Physician 1: The patient is a 44-year-old male originally diagnosed with Stage IVB Hodgkin’s Disease in 1975 treated with C-MOP chemotherapy and a single fraction of thoracic radiation. He next presented in June 2004 with an abnormal chest X-ray showing a spiculated 1.4cm nodule in the right upper lobe. Ultimately he underwent resection of an invasive non-small cell lung cancer and per the record, he had a 1.7cm lung tumor resected with pleural invasion but no nodal involvement He received no adjuvant therapy for what appears to have been a Stage I lung cancer. Within the same timeframe he was noted to have a progressive thrombocytopenia and was subsequently diagnosed with myelodysplastic syndrome (MDS).
Physician 1: The patient is a 54-year-old woman with a history of diabetes mellitus for 22 years. She is status post a kidney/pancreas transplant in 2001, with a repeat pancreas transplant in 2002. In addition, she has had persistent nausea and vomiting secondary to diabetic gastroparesis for over two years. The patient’s gastric emptying study is consistent with gastroparesis with 2-hr retention of 65% and 4-hr retention of 38%. The patient has tried Reglan, erythromycin and domperidone without success. She has lost approximately 30 pounds in the last 2 years, and lost 8 pounds in the last 3 weeks. She also has a history of diarrhea secondary to bacterial overgrowth for which she has been treated with various antibiotics. Because of persistent nausea and vomiting, the patient is requesting gastric electrical stimulation (GES) using the Enterra device.
Where the denial was upheld
Physician 1The patient is a 45-year-old man who was diagnosed with Crohn’s disease in 1988. In addition to bowel manifestations, the patient has experienced pyoderma gangrenosum. He has undergone treatment with Rowasa enemas, sulfasalazine, 6-MP, and Remicade. A diverting ileostomy was performed because of colitis from the rectum to the hepatic flexure with a rectal stricture and anal fistula. The patient has requested authorization for treatment under a protocol for stem cell transplantation after immune ablation. The Health Plan has denied authorization for the requested procedure on the basis that it is considered experimental.The requested procedure is unproven and is being conducted under institutional IRB approval. The technique is a radical departure from standard treatments, and involves a substantial risk of morbidity and mortality.
Physician 1: The patient is a 16-year-old male with pulmonary metastasis and recurrent osteosarcoma. His initial chemotherapy regimen included doxorubicin, high-dose methotrexate and cisplatin. He now has several pulmonary metastases, thought to be non-resectable following surgical exploration. Prior to this, the patient had previous metastatic lung lesions resected and had a local recurrence, for which he underwent a limb amputation. The patient and his family have declined chemotherapy (other than initial chemotherapy for primary disease) with each recurrence. A request has been made for authorization for the patient to undergo cryotherapy for treatment of the pulmonary lesions.
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 category of care 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 specialty procedures, 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