Breast Augmentation for Cancer: 50.0% of denials overturned
In 10 California IMR decisions from 2004 to 2024, reviewers overturned 5 (50.0%). In the last five years: 100.0% of 2. 8 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2024 | 1 | 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. | 4 | 50.0% | 50.0% |
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: The patient has requested authorization and coverage for flap island pedicle breast reconstruction and abdominoplasty. Surgical breast procedure to utilize excess loose abdominal tissue (excision excessive skin and subcutaneous tissue, abdomen, infraumbilical panniculectomy) as a replacement for skin and volume loss of the left breast lower pole and formation of …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast reconstructive procedure. Based on a review of the current medical literature and the American Society of Plastic Surgeons (ASPS) criteria, the requested bilateral breast reconstructive procedure is medically necessary and reconstructive in nature for treatment of this patient. The records document that the patient presents …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction surgery. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s condition. The submitted documentation supports the medical necessity of the procedure at issue.The patient with evidence of bilateral breast deformity, mild to moderate …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for removal of intact mammary implant (CPT 19328-50), periprosthetic capsulectomy of breast (CPT 19371-50), and breast reconstruction (CPT 19366-50). Regarding textured breast implants and anaplastic large cell lymphoma associated with breast implant (BIA-ALCL), the most recent U.S. Food and Drug Administration (FDA) recommendations state that, “literature reported various estimates that …”
- 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 Breast Augmentation denials for Cancer overturned?
In 10 California IMR decisions from 2004 to 2024, reviewers overturned 5 (50.0%). In the last five years: 100.0% of 2. 8 were medical-necessity disputes, 2 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.