MRI for Cardiac/Circ Problem: 38.5% of denials overturned
In 26 California IMR decisions from 2003 to 2025, reviewers overturned 10 (38.5%). In the last five years: 50.0% of 10. 23 were medical-necessity disputes, 3 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2022 | 3 | 33.3% |
| 2024 | 3 | 33.3% |
| 2025 | 2 | 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. | 11 | 36.4% | 38.5% |
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: A patient has requested reimbursement for magnetic resonance lymphangiography (MRL). In this case, the patient reported that she was experiencing painful lower left extremity symptoms, including swelling. Conservative therapy with compression stockings and physical therapy provided minimal improvement for the patient. The findings of the patient’s LAS were consistent with near-complete lymphatic obstruction of the …”
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance angiography (MRA) of the abdomen with and without contrast material. Findings: The physician reviewer found that findings on abdominal ultrasound, computed tomography, and upper endoscopy may commonly be unremarkable. Per the medical records, the patient has not undergone dynamic cross-sectional imaging. While the patient appears …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck. A patient who presents with paresthesias in four limbs may have a polyneuropathy or a spinal cord lesion. Poor coordination or unsteady gait may be due to either primarily central or peripheral dysfunction. Researchers note …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A 54-year-old male patient has requested reimbursement for magnetic resonance imaging (MRI) of lower extremity. In the setting of suspected lower extremity deep venous thrombosis (DVT), duplex lower extremity Doppler ultrasound is recommended to determine the extent of the thrombus and the acuity. It is approximately 94% sensitive and specific in the diagnosis of DVT. …”
- 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 Cardiac/Circ Problem overturned?
In 26 California IMR decisions from 2003 to 2025, reviewers overturned 10 (38.5%). In the last five years: 50.0% of 10. 23 were medical-necessity disputes, 3 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.