Need Direction

[gryndor]

What is the name of your state (only U.S. law)? California

I am looking for someone familiar with the California Department of Managed Health Care, specifically the IMR decision process.

I was seeking medical treatment from my health plan, and they denied it based on "lack of medical necessity" offering me an alternative treatment which is proveably inferior. I went through the internal appeals process before I submitted my complaint to the DMHC and they accepted it for an IMR. I have a lawyer and a doctor friend who helped me with the appeals process and so with their wealth of experience and my own exhaustive research, we wrote a killer appeal. Ultimately it was denied, saying that while I qualify for the procedure (and like 99% of people who appeal to the DMHC for this very same thing get a decision in their favor) I'm missing a certain test that makes it "impossible to determine medical necessity at this time." This missing test is not a requirement by my health plan (while they cover it, they don't perform the procedure), nor is it available or necessary until just before surgery, and only by the specialist that actually performs the procedure. It is also not something that's been a requirement of the evaluation process for anyone else and frankly makes no sense. Conceivably, if I resubmitted with some cobbled-together version of this made up test, I would be approved.

My lawyer friend is pissed and contacted the DMHC on my behalf, and got my case sent for a quality review but all the follow-up since then is super ambiguous and unstructured. Does anyone know if I'm limited to the number of IMRs I can file on the same subject, or a timeframe in which I can resubmit? Is there a process for dealing with an inherently flawed decision by MAXIMUS, once they've adopted their decision? The DMHC says my IMR decision does have some issues, and they're trying to figure out how to proceed. What is the remedy here?

I read through the Knox-Keene Act and while it explains in detail what happens when an IMR is decided in my favor, it is completely silent on what happens if it isn't, and what to do if there's a serious error discovered in the IMR decision process. Is there further literature or guidelines I can go through?

Thank you.

 

[ecmst12]

The IMR is the end of the road. The doctor who will be performing the procedure is the one who should be writing the appeal anyway, and if they say you need this particular test to determine if you meet criteria for the procedure, then you need to get that test. It's really that simple.

 

[gryndor]

The IMR is the end of the road. The doctor who will be performing the procedure is the one who should be writing the appeal anyway, and if they say you need this particular test to determine if you meet criteria for the procedure, then you need to get that test. It's really that simple.

So then I'm a completely unique case? Because the DMHC already contacted me saying there were issues with my IMR decision and that they were trying to figure out what to do and how to proceed. They're questioning MAXIMUS on their process and telling me they're likely to send it in for another IMR with a different reviewer.

Also, my potential surgeon has written me a multi-page letter of medical necessity but isn't writing the appeal itself. My doctor and lawyer friends help enrollees like me write our own appeals letters, because that appears to be the standard. I hadn't heard of a doctor writing the entire appeal letter...

 

[ecmst12]

So if they're allowing a 2nd review, consider yourself fortunate. It would still be wise to get the test done.

 

[gryndor]

So if they're allowing a 2nd review, consider yourself fortunate. It would still be wise to get the test done.

Understood. Thank you.