CT Scan for Prevention/Good Hlth: 30.8% of denials overturned
In 13 California IMR decisions from 2002 to 2025, reviewers overturned 4 (30.8%). In the last five years: 0.0% of 3. 11 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
| 2024 | 1 | 0.0% |
| 2025 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 25.0% | 30.8% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 0.0% | 30.8% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 66.7% | 30.8% |
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 enrollee has requested coverage for CT colonoscopy. She has a history of hypothyroidism, migraines, basal cell skin cancer, pre-diabetes mellitus, osteopenia, and appendectomy. She had a sigmoidoscopy that was negative and the plan was for a repeat procedure in five years. The enrollee had a gastroenterology consult for screening colonoscopy and reported a …”
“Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for a computed tomography (CT) scan of the abdomen and pelvis. Findings: The physician reviewer found that in the medical literature reported that “non-contrasted CT is a sensitive imaging modality for the detection of urinary tract calculi and obstruction.” Studies concluded that the majority of the patients evaluated …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) scan of the chest for evaluation of his medical condition. Findings: The physician reviewer found that there is sufficient support for the requested services in this patient’s case. Previously, a CT scan revealed what was thought to be benign pulmonary nodules. In a patient at high risk, …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a computed tomography (CT) scan of the heart with calcium scoring. Based on the records provided, the patient has some coronary risk. However, the record establishes that the patient has no history of disease. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for …”
- 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 Prevention/Good Hlth overturned?
In 13 California IMR decisions from 2002 to 2025, reviewers overturned 4 (30.8%). In the last five years: 0.0% of 3. 11 were medical-necessity disputes, 2 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.