Biopsy for Cancer: 45.0% of denials overturned
In 20 California IMR decisions from 2003 to 2021, reviewers overturned 9 (45.0%). In the last five years: 100.0% of 1. 6 were medical-necessity disputes, 13 experimental/investigational, 1 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Guardant360 biopsy-free tumor sequencing test. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of breast cancer note that mutational testing for metastatic tumors may suggest some targeted therapies, and specifically mention liquid biopsies. Shimelis and colleagues report that patients with mutations identified by multigene hereditary cancer …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a biopsy on the right breast mass. Based on the documentation provided for review, this patient’s imaging has not revealed any suspicious masses that are concerning for malignancy. However, the patient has consistently complained of a painful mass in her breast. In addition, this mass has been …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 Comprehensive Liquid Biopsy.Findings: Two of the three physician reviewers found molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network advises broader molecular profiling with the goal of identifying …”
And one the reviewer upheld
“An enrollee has requested authorization and coverage for mastectomy, simple, complete, biopsy or excision of lymph node(s), open, deep axillary node(s), injection procedure, radioactive tracer for identification of sentinel node, and lymphatics and lymph nodes imaging. Based on the patient’s family history, workup, and genetic counseling, she is thought to have an increased risk of breast cancer. The patient has …”
- 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 Biopsy denials for Cancer overturned?
In 20 California IMR decisions from 2003 to 2021, reviewers overturned 9 (45.0%). In the last five years: 100.0% of 1. 6 were medical-necessity disputes, 13 experimental/investigational, 1 urgent care.
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.