Genetic/Genomic Test for Cardiac/Circ Problem: 58.3% of denials overturned
In 24 California IMR decisions from 2018 to 2024, reviewers overturned 14 (58.3%). In the last five years: 60.0% of 15. 2 were medical-necessity disputes, 22 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 75.0% |
| 2022 | 2 | 50.0% |
| 2023 | 4 | 75.0% |
| 2024 | 5 | 40.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 80.0% | 58.3% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 25.0% | 58.3% |
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 a Factor V Leiden gene test and/or F2 Prothrombin gene test. Deep venous thrombosis and pulmonary embolism or arterial thromboses may be caused by hereditary thrombophilias. The increased risk is worth knowing, especially in situations of prolonged immobility. The complications may be prevented by …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genomic laboratory tests. Deep venous thrombosis and pulmonary embolism or arterial thromboses may be caused by hereditary thrombophilias. The increased risk is worth knowing, especially in situations of prolonged immobility such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions and …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ambry Genetics Corporation cardiac arrhythmia panel with KCNQ1 gene analysis. The records provided for review document that this patient’s sister experienced syncope and was found to have pathology in the KCNQ1 gene, confirming a diagnosis of congenital LQTS1, an autosomal dominant disorder. As noted in the medical …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an F2 genetic test. The records indicate that standard stroke workup (particularly cardiac workup), as well as studies to rule out alternate diagnoses such as seizures, were still pending at the time of the testing at issue. It would have been reasonable to follow up on standard and established …”
- 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 Cardiac/Circ Problem overturned?
In 24 California IMR decisions from 2018 to 2024, reviewers overturned 14 (58.3%). In the last five years: 60.0% of 15. 2 were medical-necessity disputes, 22 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.