MRI for Prevention/Good Hlth: 42.1% of denials overturned
In 38 California IMR decisions from 2002 to 2025, reviewers overturned 16 (42.1%). In the last five years: 83.3% of 6. 22 were medical-necessity disputes, 16 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2023 | 2 | 100.0% |
| 2024 | 1 | 100.0% |
| 2025 | 1 | 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. | 12 | 33.3% | 42.1% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 6 | 50.0% | 42.1% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 25.0% | 42.1% |
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 reimbursement for bilateral breast magnetic resonance imaging (MRI) with and without contrast. According to the American College of Radiology (ACR) Appropriateness Criteria, breast MRI evaluation is recommended for patients over 40 years of age with suspicion of silicone implant complications or rupture. Specifically, MRI can detect …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). The American College of Radiology (ACR) appropriateness criteria for breast cancer screening indicate that breast MRI, with and without intravenous (IV) contrast, is usually appropriate for supplemental breast cancer screening in high-risk patients with dense breasts. …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a contrast-enhanced magnetic resonance imaging (MRI). Due to the patient’s PALB2 genetic mutation, patient is considered high-risk for developing pancreatic cancer. Therefore, an MRI is recommended by the medical literature as the first-line examination for screening, which would also serve as a …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging. The indications for breast MRI include high and intermediate risk screening, for patients with a new diagnosis of breast cancer, for evaluation of response to chemotherapy prior to surgery, for evaluation of recurrence and metastatic cancer of an unknown primary source, and when …”
- 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 Prevention/Good Hlth overturned?
In 38 California IMR decisions from 2002 to 2025, reviewers overturned 16 (42.1%). In the last five years: 83.3% of 6. 22 were medical-necessity disputes, 16 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.