Implant Removal for GU/ Kidney Disorder: 27.3% of denials overturned
In 11 California IMR decisions from 2019 to 2025, reviewers overturned 3 (27.3%). In the last five years: 33.3% of 9. 10 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2022 | 2 | 0.0% |
| 2023 | 1 | 100.0% |
| 2024 | 2 | 0.0% |
| 2025 | 3 | 33.3% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for left breast surgery including anesthesia. Per the medical records, the patient had an intracapsular rupture of a silicone gel breast implant. As such, capsular revision and the removal of implant/implant contents were medically indicated. Therefore, revision of the peri-implant capsule in the breast and …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging of the right breast. Breast magnetic resonance imaging (MRI) is the gold standard imaging examination for the evaluation of silicone implant rupture. Due to the nature of silicone implants and the capsule that the body forms around the implant, intracapsular rupture, or rupture contained …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20.At issue is whether breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20 was medically necessary for treatment of the patient’s medical condition. Does the …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for removal of breast implants. The enrollee is requesting removal of saline breast implants, including one that has ruptured. The rupture of a saline implant has no adverse effect on the body. Medical literature shows that saline implant rupture results in harmless extravasation of isotonic saline that is …”
- 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 Implant Removal denials for GU/ Kidney Disorder overturned?
In 11 California IMR decisions from 2019 to 2025, reviewers overturned 3 (27.3%). In the last five years: 33.3% of 9. 10 were medical-necessity disputes, 1 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.