Genetic/Genomic Test for Mental Disorder: 9.5% of denials overturned
In 21 California IMR decisions from 2018 to 2025, reviewers overturned 2 (9.5%). In the last five years: 0.0% of 12. 4 were medical-necessity disputes, 17 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 0.0% |
| 2022 | 3 | 0.0% |
| 2023 | 1 | 0.0% |
| 2024 | 5 | 0.0% |
| 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. | 13 | 7.7% | 9.5% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 0.0% | 9.5% |
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
“An enrollee has requested authorization and coverage for genetic testing to determine if he has a form of trisomy 8. Since 2010, chromosomal microarray (CMA) has been recognized as standard of care for assessment of individuals with neurodevelopmental disorders, including autism spectrum disorders and intellectual disability. While the specific test requested to identify potential mosaic trisomy 8 is not described …”
“Nature of Statutory Criteria/ Case Summary: The enrollee’s parent requested reimbursement for genetic testing. The patient has a history of speech delays, attention-deficit/hyperactivity disorder, and learning disabilities. She had a brain illness fifteen months before the office examination described in the medical record. After her recovery, she displayed more memory and learning problems. She was diagnosed with mild autism spectrum …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested reimbursement for IDgenetix Pharmacogenomic (PGx) test. Current consensus in the medical literature, including guidelines from the American Academy of Child and Adolescent Psychiatry and recent systematic reviews, does not support routine use of combinatorial pharmacogenomic testing, including IDgenetix, for treatment selection in children and adolescents …”
- 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 Mental Disorder overturned?
In 21 California IMR decisions from 2018 to 2025, reviewers overturned 2 (9.5%). In the last five years: 0.0% of 12. 4 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.