Genetic/Genomic Test for GU/ Kidney Disorder: 26.3% of denials overturned
In 19 California IMR decisions from 2018 to 2025, reviewers overturned 5 (26.3%). In the last five years: 23.1% of 13. 2 were medical-necessity disputes, 17 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 0.0% |
| 2022 | 2 | 50.0% |
| 2023 | 6 | 0.0% |
| 2025 | 3 | 66.7% |
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. | 6 | 0.0% | 26.3% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 16.7% | 26.3% |
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 Natera Renasight genetic panel test. If caught early, medical management for autosomal dominant polycystic kidney disease (ADPKD) is altered to optimize blood pressure, monitor kidney functioning more frequently, and to monitor for other organ involvement. Gene testing is indicated to establish or confirm the …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an AlloSure kidney test. AlloSure is a non-invasive assay that can detect early rejection of an allograft. The main benefit of the test at issue is that AlloSure allows for early detection of rejection, thereby reducing injury to the allograft and hopefully preserving allograft …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for BRACAnalysis and Myriad MyRisk Hereditary Cancer Gene Test. In this case, notes reported that the patient’s paternal grandmother had ovarian cancer. As the patient has a second degree relative, of any age, with ovarian cancer, she meets the criteria for genetic testing under current guidelines by the National Comprehensive …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient’s parent has requested reimbursement multitarget polymerase chain reaction (PCR) testing for bacterial vaginosis. The American College of Obstetricians and Gynecologists (ACOG) guidelines on vaginitis in nonpregnant patients report that microscopy is the first-line diagnostic test for vulvovaginal candidiasis and trichomoniasis. The Centers for Disease Control and Prevention (CDC) notes that the gold standard …”
- 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 GU/ Kidney Disorder overturned?
In 19 California IMR decisions from 2018 to 2025, reviewers overturned 5 (26.3%). In the last five years: 23.1% of 13. 2 were medical-necessity disputes, 17 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.