Mammography for Cancer: 93.0% of denials overturned
In 57 California IMR decisions from 2008 to 2020, reviewers overturned 53 (93.0%). 2 were medical-necessity disputes, 55 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 18 | 83.3% | 93.0% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 9 | 100.0% | 93.0% |
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: 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 …”
“Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for diagnostic mammogram and SAVI placement of left breast. The enrollee who underwent routine mammography that showed new calcifications in the left breast. These were confirmed by magnification views and biopsied. Pathology showed low grade ductal carcinoma in situ (DCIS) of the left breast. The patient underwent SAVI placement followed …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast tomosynthesis performed for evaluation of the enrollee’s calcifications in the left breast. Findings: The three reviewers found that in this case, the initial breast tomosynthesis performed was warranted to better evaluate the area of developing pleomorphic calcifications. One of the primary arguments supporting the use of tomosynthesis …”
- 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 for Cancer overturned?
In 57 California IMR decisions from 2008 to 2020, reviewers overturned 53 (93.0%). 2 were medical-necessity disputes, 55 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.