CT Scan for Cardiac/Circ Problem: 19.3% of denials overturned
In 176 California IMR decisions from 2002 to 2025, reviewers overturned 34 (19.3%). In the last five years: 19.4% of 31. 46 were medical-necessity disputes, 128 experimental/investigational, 2 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 6 | 50.0% |
| 2022 | 10 | 30.0% |
| 2023 | 2 | 0.0% |
| 2024 | 3 | 0.0% |
| 2025 | 10 | 0.0% |
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. | 28 | 10.7% | 19.3% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 26 | 15.4% | 19.3% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 24 | 25.0% | 19.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 12.5% | 19.3% |
| Urgent or emergencyThe findings mention urgency. | 4 | 0.0% | 19.3% |
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
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cardiac calcium score computerized tomography (CT) scan. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on the prevention of cardiovascular disease note that coronary artery calcium scoring (CACS) may valuable, actionable information. This is particularly if the CACS is zero, which would obviate …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for chest CT scan and/or abdomen and pelvis CT scan. The records indicate that this patient presented with a five-month history of intermittent chest pain and shortness of breath. The patient has undergone a thorough cardiac work-up, which was negative for arrythmias, exercise induced ischemia, or structural abnormalities as evaluated …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coronary artery calcification computed tomography (CT) scan. The records provided for review document that this patient has a less than 7% risk of atherosclerotic cardiovascular disease in 10-years, which is considered borderline. Measurement of a coronary artery calcium score in this patient with borderline increased risk may serve as …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for computed tomography (CT) of the heart scan without contrast with quantitative evaluation of coronary calcium. Based on current published guidelines, a coronary artery calcium score (CACS) is not indicated for this patient with a low-density lipoprotein cholesterol (LDL-C) of a value within a mildly elevated range, no …”
- 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 Cardiac/Circ Problem overturned?
In 176 California IMR decisions from 2002 to 2025, reviewers overturned 34 (19.3%). In the last five years: 19.4% of 31. 46 were medical-necessity disputes, 128 experimental/investigational, 2 urgent care.
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.