Lab Work for Infectious Disease: 39.4% of denials overturned
In 33 California IMR decisions from 2008 to 2025, reviewers overturned 13 (39.4%). In the last five years: 53.3% of 15. 6 were medical-necessity disputes, 27 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 2 | 100.0% |
| 2023 | 1 | 100.0% |
| 2024 | 6 | 33.3% |
| 2025 | 6 | 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. | 9 | 33.3% | 39.4% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 39.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 39.4% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for any or all of the components of the Tick-Borne Disease, Acute Molecular Panel (infectious agent detection by nucleic acid for: Ehrlichia chaffeensis; Borrelia miyamotoi; Anaplasma phagocytophilum; and Babesia microti. Although a two-tiered serological/antibody test is the widely accepted modality for diagnosing the most common …”
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a liver fibrosis test. FibroTest (liver fibrosis test) has demonstrated that it reliably determines the presence of advanced fibrosis and cirrhosis in a variety of liver diseases, including hepatitis B. Liver biopsy, by contrast, is invasive, with risks including bleeding and bile duct injury. It is also subject to …”
“Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for laboratory testing (tick-borne disease panel – CPT codes 87469, 87484, and 87468). Anaplasmosis and ehrlichiosis are infections with an incubation period of five to 14 days following an infected tick bite. Per the medical records, the patient reported tick exposure five weeks before the diagnostic tests were ordered. Since …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for test for rabies and rabies Post-Exposure Prophylaxis (PEP) drug. In this case, the submitted documentation does not support the medical necessity of the requested test for rabies. The patient’s illness/symptoms occurring over a three-week period without progressive neurological decline is a negative …”
- 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 Infectious Disease overturned?
In 33 California IMR decisions from 2008 to 2025, reviewers overturned 13 (39.4%). In the last five years: 53.3% of 15. 6 were medical-necessity disputes, 27 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.