Biologics for Cancer: 30.4% of denials overturned
In 23 California IMR decisions from 2018 to 2025, reviewers overturned 7 (30.4%). In the last five years: 30.8% of 13. 16 were medical-necessity disputes, 7 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 25.0% |
| 2022 | 2 | 50.0% |
| 2023 | 2 | 0.0% |
| 2025 | 5 | 40.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 10 | 30.0% | 30.4% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 33.3% | 30.4% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Verzenio Tablet 150 mg. Findings: The physician reviewer found that U.S. Food and Drug Administration (FDA) has approved Verzenio for the treatment of patients with breast cancer, to be taken in combination with endocrine therapy such as tamoxifen or another aromatase inhibitor, or as monotherapy in advanced …”
“The physician reviewer found that a patient has requested authorization and coverage for Besremi. Newer studies indicate that ropeginterferon alfa-2a, a pegylated interferon-α, provides a more favorable toxicity profile than conventional interferon-α, and its prolonged activity is compatible with once-weekly dosing. In this clinical setting, current data and expert recommendations support the use of Besremi as likely to be more …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Besremi. The available records document that this patient has low-risk polycythemia vera. The patient’s provider has recommended treatment with Besremi. The U.S. Food and Drug Administration (FDA) has approved Besremi for the treatment of patients with polycythemia vera. Per the National Comprehensive Cancer Network (NCCN) guidelines, cytoreduction …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for brand name Sprycel tablets. This patient presents with chronic myeloid leukemia that has been well-managed with dasatinib. The patient is requesting treatment with the brand name formulation of dasatinib, Sprycel. The records demonstrate that this patient has been in a deep molecular remission, as evidenced by the …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Biologics denials for Cancer overturned?
In 23 California IMR decisions from 2018 to 2025, reviewers overturned 7 (30.4%). In the last five years: 30.8% of 13. 16 were medical-necessity disputes, 7 experimental/investigational.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.