Endoscopy denials: 56.1% overturned by independent reviewers
In 41 California IMR decisions from 2019 to 2026, reviewers overturned the plan 23 times (56.1%). In the last five years: 59.1% of 22. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Digestive System/ GI | 34 | 55.9% | 62.5% of 16 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 50.0% |
| 2022 | 4 | 50.0% |
| 2023 | 7 | 57.1% |
| 2024 | 3 | 100.0% |
| 2025 | 3 | 33.3% |
| 2026 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 18 | 55.6% | 56.1% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 11 | 72.7% | 56.1% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 7 | 71.4% | 56.1% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 28.6% | 56.1% |
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 authorization and coverage for (1) administration of Botox during esophagogastroduodenoscopy and (2) monitored anesthesia care. Per the medical records, the patient has gastroparesis and has failed medical therapy, and pyloromyotomy is being considered. Response to pyloric botulinum toxin injection may be predictive of response to pyloromyotomy …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for esophagogastroduodenoscopy (EGD). Clinical guidelines support endoscopic evaluation in patients at increased risk for gastric cancer, including those with a family history of the disease. Endoscopy is an effective method for detecting precancerous changes and guiding surveillance and management. In this case, the patient …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient with a diagnosis of gastroesophageal reflux disease (GERD) has requested authorization and coverage for an esophagogastroduodenoscopy (EGD). The submitted documentation supports the request for EGD with biopsies as medically necessary for the evaluation of this patient. Clinical guidelines recommend endoscopy for the evaluation of upper gastrointestinal symptoms such …”
- 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 Endoscopy denials overturned?
In 41 California IMR decisions from 2019 to 2026, reviewers overturned the plan 23 times (56.1%). In the last five years: 59.1% of 22.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.