Cancer Rx for Cancer: 45.3% of denials overturned
In 139 California IMR decisions from 2021 to 2025, reviewers overturned 63 (45.3%). In the last five years: 45.3% of 139. 82 were medical-necessity disputes, 57 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 21 | 33.3% |
| 2022 | 19 | 31.6% |
| 2023 | 27 | 40.7% |
| 2024 | 29 | 69.0% |
| 2025 | 43 | 44.2% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 57 | 45.6% | 45.3% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 35 | 31.4% | 45.3% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 9 | 11.1% | 45.3% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 7 | 14.3% | 45.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 0.0% | 45.3% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 4 | 75.0% | 45.3% |
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 a patient has requested authorization and coverage for Orgovyx. Per the medical records, the patient has node-positive recurrent prostate cancer. The U.S. Food and Drug Administration (FDA) approves the use of Orgovyx (relugolix) for the treatment of advanced prostate cancer. The National Comprehensive Cancer Network guidelines for the management of prostate cancer support its use …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bortezomib. T-cell acute lymphoblastic leukemia (T-ALL) is initially treated with chemotherapy to induce remission. Hyper-CVAD is one of the most common induction regimens used in adults, but regimens have varied to involve agents from pediatric clinical trials since these regimens are associated …”
“The physician reviewer found that a patient has requested authorization and coverage for Tibsovo. There are many reasons why a patient may forego an initial chemotherapy recommendation, especially in cases of cholangiocarcinoma, where long-term survival rates are underwhelming. This patient has progressive disease and symptoms due to tumor progression and ascites. Tibsovo is U.S. Food and Drug Administration (FDA)-approved and …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for KEYTRUDA® (pembrolizumab). Per the National Comprehensive Cancer Network (NCCN) guidelines, checkpoint inhibitors/immunotherapy, such as pembrolizumab, is recommended for patients with deficient mismatch repair (dMMR)/microsatellite instability (MSI)-high or polymerase epsilon (POLE)/polymerase delta 1 (POLD1) mutation phenotype with ultra-hypermutated (e.g., tumor mutational burden (TMB) greater than 50 mut/Mb) colon …”
- 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 Cancer Rx denials for Cancer overturned?
In 139 California IMR decisions from 2021 to 2025, reviewers overturned 63 (45.3%). In the last five years: 45.3% of 139. 82 were medical-necessity disputes, 57 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.