External Review Results
Oregon's External Review law for health insurance denials has been in effect since July 1, 2002. People who have appealed a denial through their insurer's internal appeals process can request that
their claim be evaluated by an independent review organization (IRO) that is separate from the insurer. The review is paid for by the insurer, and is free of charge for the enrollee.
This links to information on external review results by independent review organization (IRO).
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Total number of External Reviews completed
July 1, 2002 through Sept. 30, 2006:
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303 |
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Number of standard, 30-day Reviews: |
295 |
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Number of expedited, 3-day Reviews: |
8 |
Reasons for review: |
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Questions of medical necessity: |
145 |
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Experimental or investigational procedures: |
72 |
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Requests for continuity of care: |
2 |
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Contract language questions ineligible for review: |
84 |
Outcomes of reviews: |
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Number of denials reversed by the IRO: |
81(27%) |
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Number of denials reversed by the insurer before Review was completed: |
7(2%) |
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Number of reviews withdrawn by the enrollee before Review was completed: |
2 (1%) |
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Number of denials upheld by the IRO: |
214 (70%) |
Denied procedures that were recently overturned:
Breast reduction surgery, Provigil, Ambien
Denied procedures that were recently upheld:
IDET therapy, IVIG, discography, Vagus nerve stimulator, artificial disc, spinal fusion, sclerotherapy, bariatric surgery, otoplasty, cancer test, testicular prosthesis, Lyrica, Penlac
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