Endoscopy for Digestive System/ GI: 55.9% of denials overturned
In 34 California IMR decisions from 2019 to 2025, reviewers overturned 19 (55.9%). In the last five years: 62.5% of 16. 25 were medical-necessity disputes, 9 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 50.0% |
| 2022 | 3 | 33.3% |
| 2023 | 5 | 80.0% |
| 2024 | 3 | 100.0% |
| 2025 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 17 | 58.8% | 55.9% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 9 | 66.7% | 55.9% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 7 | 28.6% | 55.9% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 6 | 66.7% | 55.9% |
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 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 …”
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an esophagogastroduodenoscopy (EGD). The current American College of Gastroenterology guidelines for gastroesophageal reflux disease recommend an endoscopy if eight weeks of proton pump inhibitor therapy is ineffective. The current medical literature also supports this recommendation. In this case, the patient had a long history of treatment with omeprazole. The …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an upper endoscopy. The upper endoscopy with biopsies is supported by the submitted documentation as medically necessary for the evaluation of this patient. The American College of Gastroenterology (ACG) guidelines for patients with gastroesophageal reflux disease (GERD) recommend endoscopy if eight weeks of proton pump inhibitor therapy is ineffective. …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested reimbursement for an esophagogastroduodenoscopy (EGD) and monitored anesthesia care (MAC) along with an approved colonoscopy. The EGD at issue is not supported by the submitted documentation. Clinical guidelines recommend an endoscopy for investigation of upper gastrointestinal symptoms when the symptoms are refractory to proton pump inhibitor that has been adequately attempted. …”
- 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 for Digestive System/ GI overturned?
In 34 California IMR decisions from 2019 to 2025, reviewers overturned 19 (55.9%). In the last five years: 62.5% of 16. 25 were medical-necessity disputes, 9 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.