You might ask yourself, What is the job of the medical director at CIMRO? Simply put, I review the peer reviewers. I review all the independent review organization (IRO) insurance reviews, a random sampling of peer review reports, and any reports that have generated questions or complaints. There are rules and accreditation standards that govern our reviews. What do I look for when conducting a review?
1. Does the reviewer answer all the questions asked?
For an IRO insurance review, the question is “Is the care requested medically necessary?” or “Is the care requested experimental/investigational?” A follow-up question, “is this care FDA- approved?” may be asked. Insurance companies typically only cover FDA approved care.
2. Is the review supported by appropriate, current literature?
IRO reports must contain reference articles. Each peer review should include supporting literature. Sometimes it is hard to know what literature to use when the standard of care is routine knowledge of a physician within the specialty. In these circumstances, I have encouraged reviewers to use general textbooks from their profession, UpToDate, or a specialty medical journal. Some reviews don’t have supporting references. This is not ideal.
3. Is the review educational and professional?
It should go without saying that reviews should have language that is courteous, respectful and without slang or excessive abbreviations. The overall tone should be educational in nature. The best reviews not only critique the care, but also provide education and recommendations about what should have been done. The question, “Was standard of care met?” requires a yes/no answer, plus an explanation as to why it was or was not met. Going one step further and explaining what care should have been given is best.
For insurance reviews, whether the judgment is to uphold or deny the adverse determination, a detailed explanation is important. With review determinations upholding the insurance company’s original decision, an explanation to the patient and treating physician on the appropriate next step is important. For instance, our oncologists do an excellent job navigating the topic of DNA testing in cancer. DNA testing often is required, and it is very technical when it is and when it is not. Our oncologists provide very specific guidance to the patient and physician, citing multiple sources of current literature and care guidelines. Our neurologists do a great job suggesting next step care for migraine management. This provides true value to the insurance industry, allowing them to reset their guidelines and rules. Value is also given to physician and patients regarding best practices.
4. Was the time reported by the physician reviewer to complete the review appropriate?
When judging appropriate time spent, I look at the number of pages of the medical record and how long it takes me to look through them all. I also look at the topic and if it might have required additional research time by the reviewer. Some questions of standard of care are more intuitive to a practicing physician. Other reviews require some degree of literature research.
Some reviewers are asked to repeatedly evaluate similar questions (I’ll return to the genetic testing question). Their answers may be the same for five reviews in a row. However, we recognize the value of both the physician reviewer’s time and expertise, and the need to stay current with best practices and guidelines.
An example of excellent documentation. Elements such as names, ages, dates, and the insurance company’s name have been redacted.
PR’s Case Summary
This X-year-old boy had normal developmental milestone progression from birth until the age of XX months. At that time, he suffered from ear infections and began to have regression in behaviors and social interaction. He was diagnosed with autism spectrum disorder at age X and oculomotor dysfunction in XXXX. He has struggled significantly since the COVID outbreak began, and some behaviors have regressed – most significantly, his ability to comply with parental instruction and applied behavior analysis therapy. He has had significant increases in negative behaviors, tantruming, and physical violence toward others and objects. He struggles with social praxis, verbal communication, and frustration tolerance. He uses the Daytrana patch approximately three to five days per week; efficacy of this intervention is not provided for review.
Provide a description of the review outcome that clearly states whether medical necessity exists for each of the health care services in dispute.
Relying on the criteria for ABA Applied Behavior Analysis in (insurance company’s) Medical Coverage Policy XXXX, I have reviewed the previous reviewer’s most recent objections to coverage.
My comments are below, with their objections in italics for reference (CIMRO Note: The original report has eight bullet points; the list has been shortened here for demonstration purposes).
• “The clinical information does not demonstrate the planned treatment intensity across all settings is consistent with the severity of XXX’s impairment, the treatment goals, or his response to treatment to date.
It appears that this is a summary statement with no data to review.
• “Additionally, the amount of supervision requested by the provider is not consistent with the generally accepted practice standard of 1-2 hours per 10 hours of direct treatment, and there was not sufficient data or clinical rationale provided related to the medical necessity of the requested supervision time.”
His documented behaviors and symptoms are quite severe; therefore, significant assistance is justified. As for the exact number of hours or for “generally accepted” practice, I do not see a published schedule by (insurance company) regarding what severity correlates with what number of hours should be provided included in the review documents. After inquiry through (the insurance company), it appears that no such schedule is published. Since there does not appear to be published guidelines, this objection seems to be based on subjective opinion, and it is not reasonable to expect the providing company to know what they are expecting. Therefore, I determine that this objection is unfounded.
Principal reason or reasons for decision, including clinical basis, findings and conclusions used to support the decision:
This patient requires significant care based on the documents provided; his need for clinical care was not questioned by the initial reviewer. He has severely disruptive behavior to include aggression and has difficulty complying which requires additional focus and support by his treatment team in order to make progress. The decision was overturned because the objections were not factual as shown by the documentation provided, or because they were subjective in nature. If very specific criteria in goal setting are required for approval, this should be published and shared with ABA therapists in advance.
Description and the source of the screening criteria or other clinical basis used to make the decision:
1. (Insurance company). Medical Coverage Policy: XX Available at: XX
Don’t forget to check the appropriate box(es) at the bottom of the worksheet to indicate the type of reference(s) being used.
Tips for writing excellent reports:
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