Colonoscopy/Sigmoid for Prevention/Good Hlth: 32.4% of denials overturned
In 37 California IMR decisions from 2006 to 2025, reviewers overturned 12 (32.4%). In the last five years: 33.3% of 3. 32 were medical-necessity disputes, 5 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
| 2023 | 1 | 0.0% |
| 2025 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 7 | 28.6% | 32.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 14.3% | 32.4% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 0.0% | 32.4% |
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 …”
“Nature of Statutory Criteria/ Case Summary: At issue was whether the anesthesia service provided was medically necessary to treat the patient’s medical condition. This is a patient that was seen by an in-plan gastroenterologist and was recommended to undergo a screening colonoscopy with monitored anesthesia care (MAC). When the colonoscopy was performed, the anesthesia provider used MAC with Propofol for …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia care for management of the enrollee’s pain during her colonoscopy. Findings: The physician reviewer found that according to the American Society of Anesthesiologists (ASA), an essential component of MAC anesthesia is the “anesthesia assessment and management of a patient’s actual or anticipated physiological derangements or medical problems …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services provided during a colonoscopy. The current guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) noted that the use of a “combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without …”
- 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 for Prevention/Good Hlth overturned?
In 37 California IMR decisions from 2006 to 2025, reviewers overturned 12 (32.4%). In the last five years: 33.3% of 3. 32 were medical-necessity disputes, 5 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.