MRI for Post Surgical Comp: 66.7% of denials overturned
In 6 California IMR decisions from 2013 to 2025, reviewers overturned 4 (66.7%). In the last five years: 33.3% of 3. 4 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2025 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the pelvis and abdomen. Findings: The physician reviewer found that Prolonged postoperative pain after recurrent inguinal hernia repair can represent technical failings of mesh movement or other anatomic abnormality. Per Andresen and Rosenberg, “The optimal management of chronic pain following inguinal hernia surgery should …”
“Nature of Statutory Criteria/Case Summary:At issue is whether the MRI of the breast that was provided likely to have been more beneficial for the evaluation of the enrollee’s condition than any available standard therapy. The enrollee presented to her provider with complaints of waking up from pain. She is status post silicone breast augmentation and subsequent cellulitis. The plan of …”
“A 38-year-old female has requested an MRI of the lower extremity, any joint, without contrast materials (CPT code 73721) for evaluation of her ankle pain. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested diagnostic procedure in this patient’s case. This patient is status post osteotomy of the ankle and a tendon transfer. …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging of the breast, without and with contrast material, including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis), when performed; bilateral. Due to the nature of silicone implants and the capsule that the body forms around the implant, intracapsular ruptures, are often not …”
- 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 Post Surgical Comp overturned?
In 6 California IMR decisions from 2013 to 2025, reviewers overturned 4 (66.7%). In the last five years: 33.3% of 3. 4 were medical-necessity disputes, 2 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.