Mastectomy for Endocrine/Metabolic: 50.0% of denials overturned
In 8 California IMR decisions from 2019 to 2025, reviewers overturned 4 (50.0%). In the last five years: 100.0% of 4. 8 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 100.0% |
| 2023 | 1 | 100.0% |
| 2025 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 25.0% | 50.0% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a mastectomy.One study stated that gynecomastia “describes excessive benign development of the male breast(s) due to proliferation of glandular tissue.” The authors noted that “Psychological consequences include depression, anxiety, disordered eating, body dysmorphic disorder, and reduced self-esteem.” The American Society of Plastic …”
“Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for a mastectomy. Gynecomastia is the presence of an abnormal proliferation of breast tissue that accounts for up to 65% of male breast disorders. Gynecomastia has a broad range of causes that are classified as either physiological or pathological, although in many cases, no specific cause can be found. In a …”
“An enrollee has requested authorization and coverage for a mastectomy (CPT code 19300).At issue is whether the requested mastectomy is medically necessary to treat the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mastectomy. According to the American Society of Plastic Surgeons (ASPS), “gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males.” However, the ASPS noted that, “in pseudogynecomastia, the breast enlargement is secondary to fat accumulation; and both glandular and fat tissue …”
- 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 Mastectomy denials for Endocrine/Metabolic overturned?
In 8 California IMR decisions from 2019 to 2025, reviewers overturned 4 (50.0%). In the last five years: 100.0% of 4. 8 were medical-necessity disputes.
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.