CT Scan for Ears/Nose/Throat: 33.3% of denials overturned
In 6 California IMR decisions from 2002 to 2025, reviewers overturned 2 (33.3%). In the last five years: 0.0% of 1. 6 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2025 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“The parent of a 13-year-old male enrollee has requested a computed tomography (CT) scan of the sinuses for evaluation of the enrollee’s sinusitis and ocular pain. Findings: The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the diagnostic procedure at issue. In this case, the patient’s symptoms included eye pain, with …”
“The patient is a 22-year-old female with chronic sinusitis and orbital headaches for six months with no improvement in her condition despite multiple courses of medications including Allegra, Biaxin, and Flonase. The patient is seeking a CT scan of the sinuses. The Health Plan has denied this request.The Health Plan’s denial should be overturned. The patient has a history of …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for a computed tomography (CT) scan of the head or brain without contrast. Clinical guidelines indicate that imaging is not routinely recommended for nonspecific dizziness in the absence of focal neurologic deficits due to low diagnostic yield. Additionally, when imaging is indicated for evaluation …”
- 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 Ears/Nose/Throat overturned?
In 6 California IMR decisions from 2002 to 2025, reviewers overturned 2 (33.3%). In the last five years: 0.0% of 1. 6 were medical-necessity disputes.
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.