Pet Scan for Cancer: 69.2% of denials overturned
In 305 California IMR decisions from 2002 to 2025, reviewers overturned 211 (69.2%). In the last five years: 70.3% of 64. 139 were medical-necessity disputes, 166 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 11 | 54.5% |
| 2022 | 14 | 64.3% |
| 2023 | 9 | 77.8% |
| 2024 | 15 | 66.7% |
| 2025 | 15 | 86.7% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 91 | 74.7% | 69.2% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 41 | 43.9% | 69.2% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 24 | 75.0% | 69.2% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 9 | 0.0% | 69.2% |
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 a patient has requested authorization and coverage for a positron emission tomography (PET) scan. In this case, the patient has a diagnosis of prostate cancer. The records establish that the patient has a pathology result indicating intermediate-risk disease, establishing intermediate-risk prostate cancer. Further, the findings of the PET scan will likely change the patient’s clinical …”
“The physician reviewer found that a patient has requested authorization and coverage for positron emission tomography with concurrently acquired computed tomography (PET/CT) scan (skull to thigh).PET/CT is most often used to evaluate for nodal and distant metastatic disease and has a sensitivity of approximately 89% and specificity of 64% in this setting. PET/CT can also exclude additional sites of metastases …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localized imaging; skull base to mid-thigh. The American College of Radiology (ACR) appropriateness criteria for follow-up of metastatic prostate cancer treated by systemic therapy notes that prostate-specific …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for POSLUMA (flotufolastat F18) positron emission tomography (PET) with computed tomography (CT). This imaging modality is designed to detect and monitor prostate cancer by targeting prostate-specific membrane antigen (PSMA). National guidelines recommend against the routine use of PSMA PET imaging for initial staging …”
- 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 Pet Scan denials for Cancer overturned?
In 305 California IMR decisions from 2002 to 2025, reviewers overturned 211 (69.2%). In the last five years: 70.3% of 64. 139 were medical-necessity disputes, 166 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.