MRI for Cancer: 55.0% of denials overturned
In 120 California IMR decisions from 2002 to 2025, reviewers overturned 66 (55.0%). In the last five years: 66.7% of 15. 64 were medical-necessity disputes, 56 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 100.0% |
| 2023 | 3 | 0.0% |
| 2024 | 5 | 100.0% |
| 2025 | 5 | 80.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 29 | 37.9% | 55.0% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 13 | 38.5% | 55.0% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 10 | 70.0% | 55.0% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 0.0% | 55.0% |
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 magnetic resonance imaging of the breast. Magnetic resonance imaging is indicated in specific clinical situations, such as in the screening of high-risk patients. Per the medical records, the patient has one first-degree and one second-degree relative with breast cancer, making her high-risk. …”
“The physician reviewer found that a patient has requested authorization and coverage for dynamic magnetic resonance imaging (MRI) of bilateral breasts. Clinical documentation indicates the presence of a breast lesion requiring surgical planning. Breast MRI can help determine the extent of such lesions, including deeper tissue involvement, and may influence the type of surgery needed. MRI with contrast can assist …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral magnetic resonance imaging (MRI) of the breasts with/without contrast. According to the American College of Radiology (ACR) appropriateness criteria for breast cancer screening based on breast density, in the setting of extremely dense breast tissue in a high-risk patient, as is …”
And one the reviewer upheld
“The physician reviewer found that a patient has requested authorization and coverage for a magnetic resonance imaging (MRI) scan of the bilateral breasts. Based on current American College of Radiology (ACR) appropriateness criteria and the medical literature, an MRI scan of the bilateral breasts is not indicated for this patient. One study suggests that imaging surveillance in this patient’s situation …”
- 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 MRI denials for Cancer overturned?
In 120 California IMR decisions from 2002 to 2025, reviewers overturned 66 (55.0%). In the last five years: 66.7% of 15. 64 were medical-necessity disputes, 56 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.