Genetic/Genomic Test for Blood Related Disord: 81.8% of denials overturned
In 11 California IMR decisions from 2019 to 2025, reviewers overturned 9 (81.8%). In the last five years: 71.4% of 7. 3 were medical-necessity disputes, 8 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2023 | 2 | 100.0% |
| 2024 | 2 | 100.0% |
| 2025 | 2 | 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. | 4 | 100.0% | 81.8% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 66.7% | 81.8% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for genetic testing for severe inherited conditions, genomic sequencing analysis panel. The testing at issue is recommended by the American College of Obstetricians and Gynecologists (ACOG). ACOG recommends offering hemoglobinopathy testing to all individuals planning a pregnancy or at the first prenatal visit if no …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement for genetic testing for inherited thrombophilia, factor II (prothrombin, coagulation factor II), factor V (coagulation factor V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant, and/or methyltetrahydrofolate reductase (MTHFR) (5,10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability)). Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be caused …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a genetic test panel (targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes). Mastocytosis describes a group of disorders in which there is a pathologic accumulation of mast cells in tissues. These diseases can be limited to …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for kidney genetic testing, Molecular Pathology Procedure (MOPATH) Level 5. In this case, given the simultaneous elevation of aldosterone and renin levels and without ruling out secondary causes, the initial step in the evaluation of the patient would be to first complete conventional diagnostic steps. According to the …”
- 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 Genetic/Genomic Test denials for Blood Related Disord overturned?
In 11 California IMR decisions from 2019 to 2025, reviewers overturned 9 (81.8%). In the last five years: 71.4% of 7. 3 were medical-necessity disputes, 8 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.