Genetic/Genomic Test for Skin Disorders: 42.9% of denials overturned
In 7 California IMR decisions from 2019 to 2025, reviewers overturned 3 (42.9%). In the last five years: 50.0% of 6. , 7 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2022 | 1 | 100.0% |
| 2023 | 2 | 50.0% |
| 2024 | 1 | 0.0% |
| 2025 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (MyPath Melanoma).Findings: Two out of three physician reviewers found that the services at issue were likely to have been more beneficial than any other available standard treatments for the enrollee’s medical condition.For a lesion suspicious of melanoma, but not confirmed by …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for myPath Melanoma gene expression profile testing.Findings: Three physician reviewers found that the patient's pathological diagnosis in this case was not definitive, as there was a compound melanocytic nevus with atypical features, and it was therefore unclear if this lesion was benign or malignant. National Comprehensive Cancer Network (NCCN) clinical …”
“Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for exome sequencing testing (CPT 81415). The provider caring for this patient has recommended whole exome sequencing (WES) for diagnostic purposes given the constellation of symptoms including enamel hypoplasia, eczema, vitiligo, xerosis, and skin hypopigmentation. In contrast to current sequencing tests that analyze one gene or small …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a MyPath melanoma test. For a melanocytic lesion of uncertain malignant potential, standard management includes excision of the lesion site with appropriate margins. Per the medical records, the dermatopathology report describes the lesion as a moderately atypical acral compound nevus, and the pathologist recommended …”
- 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 Skin Disorders overturned?
In 7 California IMR decisions from 2019 to 2025, reviewers overturned 3 (42.9%). In the last five years: 50.0% of 6. , 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.