MRI for Foot Disorder: 25.0% of denials overturned
In 8 California IMR decisions from 2010 to 2025, reviewers overturned 2 (25.0%). In the last five years: 33.3% of 3. 7 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2024 | 2 | 50.0% |
| 2025 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 33.3% | 25.0% |
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: The patient requested reimbursement for a magnetic resonance imaging (MRI) study.According to the American College of Radiology (ACR) appropriateness criteria, an MRI of the foot may be appropriate for further evaluation of persistent foot pain after initial negative radiographs. An MRI can assist in the evaluation of soft tissue and …”
“A 51-year-old female enrollee has requested an MRI of the lower extremities (feet/ankles) for evaluation of her bilateral foot pain. Findings: Two physician reviewers found that this patient has disabling bilateral foot pain. Her underlying diagnosis is consistent with unknown connective tissue disorder. Her symptoms may reflect plantar fasciitis, but also could reflect other inflammatory conditions. MRI is the best …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right foot. In this case, there is no suspicion based on the clinical records that the patient has suffered a tear of the tendons of the foot or ankle. A review of the records reveals that …”
- 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 Foot Disorder overturned?
In 8 California IMR decisions from 2010 to 2025, reviewers overturned 2 (25.0%). In the last five years: 33.3% of 3. 7 were medical-necessity disputes, 1 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.