Mammography denials: 93.2% overturned by independent reviewers
In 784 California IMR decisions from 2006 to 2021, reviewers overturned the plan 731 times (93.2%). In the last five years: 100.0% of 1. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Prevention/Good Hlth | 473 | 93.9% | — |
| OB-GYN/ Pregnancy | 242 | 91.7% | — |
| Cancer | 57 | 93.0% | — |
| Not Applicable | 7 | 100.0% | — |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 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. | 212 | 91.5% | 93.2% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 167 | 99.4% | 93.2% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 11 | 9.1% | 93.2% |
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
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for digital breast tomosynthesis (3D mammogram).The main weakness of mammography is the detection of cancer in women with radiographic dense breasts. While nearly all cancers will be apparent in fatty breasts, only half will be visible in extremely dense breasts. This is a result of the masking or …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for three-dimensional (3D) breast mammography (breast tomosynthesis). The National Comprehensive Cancer Network (NCCN) recommends annual mammogram for the surveillance of patients who are at increased risk for breast cancer and possible tomosynthesis in certain clinical settings. Rafferty and colleagues reported that the “addition of tomosynthesis to digital mammography …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for three-dimensional (3D) mammogram (breast tomosynthesis). The standard of care for detection and work-up of breast calcifications is high quality two-dimensional (2D) digital mammogram with spot compression magnification. There is no known advantage to 3D tomosynthesis over standard 2D digital mammography in this clinical setting. 3D tomosynthesis mammograms …”
- 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 Mammography denials overturned?
In 784 California IMR decisions from 2006 to 2021, reviewers overturned the plan 731 times (93.2%). In the last five years: 100.0% of 1.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.