Genetic/Genomic Test for Pregnancy/Childbirth: 48.4% of denials overturned
In 31 California IMR decisions from 2019 to 2025, reviewers overturned 15 (48.4%). In the last five years: 33.3% of 12. 6 were medical-necessity disputes, 25 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 0.0% |
| 2023 | 3 | 0.0% |
| 2024 | 3 | 33.3% |
| 2025 | 3 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 8 | 12.5% | 48.4% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 6 | 16.7% | 48.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 0.0% | 48.4% |
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 has requested reimbursement for the Natera Horizon 274 gene panel test. Multiple societal guidelines indicate that carrier screening should be offered for patients who are currently pregnant or considering pregnancy and who have not previously undergone carrier screening. Specifically, the American College of Medical Genetics (ACMG) states that all pregnant patients or patients …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for non-invasive prenatal testing (NIPT). Findings: The physician reviewer found that Aneuploidy, commonly resulting from non-disjunction during meiosis I or II or mitosis, leads to trisomic or monosomic zygotes, such as those seen in Patau syndrome (T13), Edward syndrome (T18), and Down syndrome (T21). Chromosomal abnormalities affect approximately 1 in …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Integrated Screen. The integrated screen is a quadruple test that measures the level of the biochemical markers alpha-fetoprotein (AFP), unconjugated estriol (uE3), human chorionic gonadotropin (hCG), and dimeric inhibin A (DIΑ) in maternal serum. The integrated screen is effective in detecting Smith-Lemli-Opitz syndrome (SLOS), …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the genomic sequencing analysis panel genetic testing for severe inherited conditions. The records indicate that this patient underwent an expanded carrier screening while she was pregnant. However, the records do not document a personal or family history of any genetic condition or ethnic group …”
- 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 Pregnancy/Childbirth overturned?
In 31 California IMR decisions from 2019 to 2025, reviewers overturned 15 (48.4%). In the last five years: 33.3% of 12. 6 were medical-necessity disputes, 25 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.