CT Scan for Cancer: 47.5% of denials overturned
In 40 California IMR decisions from 2003 to 2025, reviewers overturned 19 (47.5%). In the last five years: 42.9% of 14. 34 were medical-necessity disputes, 6 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 25.0% |
| 2022 | 2 | 100.0% |
| 2023 | 3 | 33.3% |
| 2024 | 3 | 33.3% |
| 2025 | 2 | 50.0% |
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. | 10 | 60.0% | 47.5% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 33.3% | 47.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 47.5% |
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 computed tomography (CT) of the thorax and a computed tomography (CT) of the abdomen and pelvis. In this case, the patient initially underwent a standard approach with thyroidectomy and thyroid hormone suppression for thyroid cancer. The patient later presented with unintended weight loss …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for computed tomography (CT) scans of the thorax and abdomen and pelvis.Early-stage colon cancer, stage I and II, are potentially curable by surgical resection. However, there are cases where subsequent metastatic disease develops despite the limited stage at initial diagnosis. Post-surgical surveillance includes history …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computerized tomography (CT) scan of the thorax. As there are no clear guidelines for the follow-up of pulmonary nodules detected on chest CT scan in patients with an extrapulmonary oncologic history, individualized risk assessment is required. In this case, the patient has a history of extrapulmonary malignancy, …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for a positron emission tomography (PET) scan with computed tomography (CT) attenuation. A PET-CT is not indicated for work-up of this patient’s left adrenal lesion. PET-CT is reserved for patients with known or suspected malignancy, or when imaging is indeterminate and malignancy is suspected. This patient has had …”
- 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 CT Scan denials for Cancer overturned?
In 40 California IMR decisions from 2003 to 2025, reviewers overturned 19 (47.5%). In the last five years: 42.9% of 14. 34 were medical-necessity disputes, 6 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.