Organ Transplant for Cancer: 25.0% of denials overturned
In 8 California IMR decisions from 2002 to 2025, reviewers overturned 2 (25.0%). In the last five years: 33.3% of 3. 6 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 0.0% |
| 2025 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 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: A patient has requested authorization and coverage for a liver transplant. Metastatic carcinoid or neuroendocrine tumor is a rare cancer that is generally not responsive to cytotoxic chemotherapy. This patient has a metastatic neuroendocrine tumor that is currently restricted to the liver. Since this patient's diagnosis, the patient’s medical care …”
“A 60-year-old male requested authorization and coverage for a liver transplant evaluation. The health plan has denied this request indicating that the requested evaluation is not medically necessary for treatment of the enrollee’s liver cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plan’s denial on the basis that the requested evaluation is …”
And one the reviewer upheld
“The physician reviewer found that The patient has requested authorization and coverage for liver transplant, tumor removal surgery, and/or radiation therapy (including, but not limited to, proton therapy and external beam radiation therapy (EBRT)). The records provided for review document that this patient presents with decompensated cirrhosis secondary to hepatitis C virus and alcohol with multifocal hepatocellular carcinoma with tumor …”
- 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 Organ Transplant denials for Cancer overturned?
In 8 California IMR decisions from 2002 to 2025, reviewers overturned 2 (25.0%). In the last five years: 33.3% of 3. 6 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.