Lab Work for Cancer: 42.2% of denials overturned
In 256 California IMR decisions from 2005 to 2024, reviewers overturned 108 (42.2%). In the last five years: 28.6% of 7. 9 were medical-necessity disputes, 247 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2022 | 2 | 0.0% |
| 2024 | 3 | 33.3% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 64 | 31.3% | 42.2% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 53 | 17.0% | 42.2% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 25 | 48.0% | 42.2% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 37.5% | 42.2% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a blood test (protein biomarker tests or 4Kscore). Based on current medical guidelines on the Early Detection of Prostate Cancer, blood and urine markers available alone or in combination are indicated to “risk stratify patients with a mildly elevated prostate-specific antigen (PSA), typically between …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (CPT 82523 collagen crosslinks) provided 3/06/21 by Quest Diagnostics. Findings: The physician reviewer found that The use of markers of bone turnover is standard practice among endocrinologists and other specialists in osteoporosis and is cited as a tool to monitor therapy in the recent Endocrine Society guidelines …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Oncotype DX testing. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Oncotype DX testing may be appropriate in select patients to guide the addition of combination chemotherapy to standard hormone therapy. Guidelines endorses the use of Oncotype …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for GeneSight® Psychotropic from Assurex Health Inc. There are mixed results in the literature on the use of Genesight testing. Health Quality Ontario concluded in a systematic review that included four studies, “There is uncertainty about the use of GeneSight Psychotropic pharmacogenomic genetic panel to …”
- 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 Lab Work denials for Cancer overturned?
In 256 California IMR decisions from 2005 to 2024, reviewers overturned 108 (42.2%). In the last five years: 28.6% of 7. 9 were medical-necessity disputes, 247 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.