Bone Density Scan for Orth/Musculoskeletal: 36.7% of denials overturned
In 60 California IMR decisions from 2002 to 2025, reviewers overturned 22 (36.7%). In the last five years: 100.0% of 3. 41 were medical-necessity disputes, 19 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 1 | 100.0% |
| 2025 | 2 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 11 | 36.4% | 36.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 7 | 71.4% | 36.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 20.0% | 36.7% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a bone density dual-energy X-ray absorptiometry (DEXA) scan. Low body weight and low body mass index are important factors affecting bone mineral density, especially in athletes. In this case, the patient is a marathon runner, has a weight of 114 pounds, and has a …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a bone density study. In 2018, the U.S. Preventative Services Task Force issued recommendations on osteoporosis screening. The Task Force endorsed screening with a bone mineral density (BMD) in female patients 65 years of age and older or postmenopausal female patients less than 65 …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the dual-energy x-ray absorptiometry (DXA) scan. Osteoporosis is defined as low bone mineral density caused by altered bone microstructure, ultimately predisposing patients to low-impact, fragility fractures. Osteoporosis is a subclinical condition until complicated by fracture(s). Any new fracture in a patient aged 50 years or older signifies imminent elevated …”
And one the reviewer upheld
“The physician reviewer found that the patient has requested reimbursement for bone density testing services. According to the National Osteoporosis Foundation guidelines, serial central DEXA testing is an important component of osteoporosis management (Cosman, et al.). More frequent testing may be warranted in certain clinical situations. The International Society of Clinical Densitometry (ISCD) guidelines indicate that intervals between bone mineral …”
- 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 Bone Density Scan denials for Orth/Musculoskeletal overturned?
In 60 California IMR decisions from 2002 to 2025, reviewers overturned 22 (36.7%). In the last five years: 100.0% of 3. 41 were medical-necessity disputes, 19 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.