Genetic/Genomic Test for Pediatrics: 81.8% of denials overturned
In 11 California IMR decisions from 2018 to 2025, reviewers overturned 9 (81.8%). In the last five years: 66.7% of 6. 4 were medical-necessity disputes, 7 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2023 | 1 | 100.0% |
| 2024 | 2 | 50.0% |
| 2025 | 2 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 100.0% | 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
“Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for Beckwith-Wiedemann Syndrome and Russell-Silver Syndrome gene test. Macroglossia is an early sign of Beckwith-Wiedemann syndrome. Genetic testing is crucial to rule out this condition since there is an increased risk of solid tumors, such as Wilms tumor and hepatoblastoma. A confirmed diagnosis would necessitate future screening, …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for whole exome plus mitome trio. Whole exome sequencing and mitochondrial testing are indicated for patients with complex medical history and developmental delays, especially if initial testing results are inconclusive. The results can confirm rare genetic disorders for which screening/management guidelines or …”
“Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for PreventionGenetics PGnome® Trio whole genome sequencing testing.Findings: Two of the three physician reviewers found the requested (PreventionGenetics PGnome® Trio whole genome sequencing testing is likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy. The clinical guidelines note that …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for a Whole Exome Plus Analysis. The American College of Medical Genetics and Genomics (ACMG) published a guideline on the use of exome and genome sequencing in pediatric patients. The guideline recommends exome sequencing and genome sequencing as a first-tier or second-tier test for patients …”
- 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 Pediatrics overturned?
In 11 California IMR decisions from 2018 to 2025, reviewers overturned 9 (81.8%). In the last five years: 66.7% of 6. 4 were medical-necessity disputes, 7 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.