PET Scan for Cardiac/Circ Problem: 63.6% of denials overturned
In 11 California IMR decisions from 2006 to 2024, reviewers overturned 7 (63.6%). In the last five years: 50.0% of 4. 5 were medical-necessity disputes, 6 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
| 2023 | 1 | 100.0% |
| 2024 | 2 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 66.7% | 63.6% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 0.0% | 63.6% |
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 a myocardial perfusion positron emission tomography (PET) scan. Stress testing, such as the type ordered in this patient’s case, is a non-invasive method to assess for the presence of myocardial ischemia due to obstructive coronary artery disease, particularly when symptoms of chest pain and/or …”
“The physician reviewer found that The patient has requested reimbursement for Absolute quantitation of myocardial blood flow (AQMBF) positron emission tomography (PET) scan. Surveillance invasive coronary angiography has low sensitivity for the detection of early small vessel or advanced diffuse cardiac allograft vasculopathy as suspected in this patient’s case. Stress echocardiography and single-photon emission computed tomography (SPECT) myocardial perfusion imaging …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan (CPT codes 78815, 78451, and HCPCS codes A9552, A9526, A9502). Based on the records for review, this patient has biopsy proven sarcoidosis. The patient’s cardiac magnetic resonance imaging (MRI) did not show cardiac involvement. However, MRI was performed in 2015, and the …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for myocardial imaging and positron emission tomography (PET) with concurrently acquired computed tomography (CT).Current medical criteria for cardiac imaging stress tests made cardiac stress testing a focal point of attention, largely due to its wide dissemination, radiation risks, procedural risks, and association with downstream testing and …”
- 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 Cardiac/Circ Problem overturned?
In 11 California IMR decisions from 2006 to 2024, reviewers overturned 7 (63.6%). In the last five years: 50.0% of 4. 5 were medical-necessity disputes, 6 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.