CT Scan for Endocrine/Metabolic: 34.5% of denials overturned
In 29 California IMR decisions from 2013 to 2025, reviewers overturned 10 (34.5%). In the last five years: 19.0% of 21. 10 were medical-necessity disputes, 19 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 25.0% |
| 2022 | 3 | 33.3% |
| 2023 | 6 | 33.3% |
| 2024 | 3 | 0.0% |
| 2025 | 5 | 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. | 11 | 18.2% | 34.5% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 9 | 44.4% | 34.5% |
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
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a cardiac computed tomography (CT) and angiography. Coronary CT angiography is a quick, non-invasive test utilizing a specialized CT scanner to obtain high-resolution three-dimensional images of the coronary arteries. A coronary CT angiography allows the provider to see whether or not plaque has developed in the coronary arteries and …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electron beam computed tomography (EBCT) - evaluation of coronary calcification. The records indicate that the patient is a non-diabetic borderline risk patient with a low-density lipoprotein (LDL) cholesterol compared to standard risk stratification alone for the purposes of guiding management decisions about statin therapy. Overall, there is …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for electron beam computed tomography (coronary artery calcification screening). This patient underwent evaluation with coronary artery calcification screening scoring to assess coronary disease risk. The records indicate that the patient is a non-diabetic intermediate risk patient with a low-density lipoprotein (LDL) cholesterol greater than 70 and less than 190 mg/dL. …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for computed tomographic (CT) angiography of the heart. Based on the records, the patient has increased coronary risk but no history of cardiovascular disease and no documented symptoms suspicious of coronary ischemia. In this primary prevention setting with increased coronary risk, treatment should …”
- 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 Endocrine/Metabolic overturned?
In 29 California IMR decisions from 2013 to 2025, reviewers overturned 10 (34.5%). In the last five years: 19.0% of 21. 10 were medical-necessity disputes, 19 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.