Genetic/Genomic Test for Ears/Nose/Throat: 80.0% of denials overturned
In 5 California IMR decisions from 2020 to 2025, reviewers overturned 4 (80.0%). In the last five years: 100.0% of 2. 1 were medical-necessity disputes, 4 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2025 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested reimbursement for SNAPSHOT-NGS-V2 assay. Desmoid fibromatosis is known to frequently recur, necessitating long-term surveillance, and may ultimately require aggressive surgical resection. Standard establishment of a tissue diagnosis for desmoid fibromatosis is via a histological analysis of a tissue biopsy. A known driver of desmoid fibromatosis …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for genetic testing and counseling (CPT 99205, 99215 x 3, 99358, 99354, 96040 x 4, S0562 x 8). This patient presents with bilateral sensorineural hearing loss (SNHL). The patient’s provider has recommended evaluation with genetic testing to assess the patient for possible congenital causes of SNHL. There …”
“Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for hereditary hearing loss deficiency deafness panel. Autosomal recessive hearing loss and other defects of the inner ear have been associated with specific genes. Researchers noted that in syndromic hearing loss, it is important to determine the syndrome and gene mutation, which can impact treatment and vital …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for hearing loss panel including whole exome and whole genome testing. Based on the available clinical documentation, the request for whole exome and whole genome testing is not likely to be more beneficial in identifying the underlying etiology of this patient’s congenital hearing loss as compared to …”
- 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 Ears/Nose/Throat overturned?
In 5 California IMR decisions from 2020 to 2025, reviewers overturned 4 (80.0%). In the last five years: 100.0% of 2. 1 were medical-necessity disputes, 4 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.