Colonoscopy/Sigmoid denials: 39.2% overturned by independent reviewers
In 102 California IMR decisions from 2005 to 2025, reviewers overturned the plan 40 times (39.2%). In the last five years: 62.5% of 16. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Digestive System/ GI | 50 | 42.0% | 63.6% of 11 |
| Prevention/Good Hlth | 37 | 32.4% | 33.3% of 3 |
| Cancer | 8 | 25.0% | — |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 66.7% |
| 2022 | 3 | 66.7% |
| 2023 | 6 | 50.0% |
| 2024 | 3 | 66.7% |
| 2025 | 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. | 23 | 47.8% | 39.2% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 21 | 38.1% | 39.2% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 19 | 10.5% | 39.2% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 3 | 0.0% | 39.2% |
| Urgent or emergencyThe findings mention urgency. | 3 | 66.7% | 39.2% |
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 authorization and coverage for a colonoscopy. In this case, the patient is at increased risk for colorectal cancer given a newly discovered family history, and no prior colonoscopy is documented. Current clinical guidelines support colonoscopy screening in patients with a family history of colorectal cancer at …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a colonoscopy procedure. Acute appendicitis is potentially a result of colorectal cancer, and patients have been found to have a higher incidence of colorectal cancer after undergoing an appendectomy. One study concluded that appendicitis is an indication for a colonoscopy in patients …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for monitored anesthesia care performed during a diagnostic colonoscopy and diagnostic esophagogastroduodenoscopy. The medical literature establishes that monitored anesthesia care (MAC) plays a significant role in facilitating the effective completion of a colonoscopy and upper endoscopy. MAC services involve the administration of intravenous sedation and analgesia to ensure …”
- 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 Colonoscopy/Sigmoid denials overturned?
In 102 California IMR decisions from 2005 to 2025, reviewers overturned the plan 40 times (39.2%). In the last five years: 62.5% of 16.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.