SCP Consult Refer for Cancer: 78.6% of denials overturned
In 14 California IMR decisions from 2004 to 2024, reviewers overturned 11 (78.6%). In the last five years: 66.7% of 3. 14 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 100.0% |
| 2024 | 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. | 5 | 80.0% | 78.6% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 33.3% | 78.6% |
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
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for office consults with a tertiary oncologist specializing in treatment of chronic myelomonocytic leukemia every four months. The medical records demonstrated that the patient’s recent bone marrow exam is consistent with myelodysplastic syndrome/myeloproliferative neoplasm in the setting of past chronic myelomonocytic leukemia (CMML). The patient’s CMML had previously …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with an oncologist at a tertiary level of care facility. This patient has a history of chronic myelogenous leukemia, which is a disorder that has both myelodysplastic and myeloproliferative features. Given the complexity of the condition, a second opinion regarding potential treatment strategies is oftentimes indicated …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation with a dermatologist. The National Comprehensive Cancer Network (NCCN) guidelines for melanoma recommend regular examinations depending on a patient’s disease course. In this case, the patient has a history of an atypical nevus that required a re-excision of the lesion to ensure removal in its …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an office visit with a cancer specialist. The National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer recommend yearly prostate-specific antigen (PSA) screening for five years after undergoing definitive therapy. In this case, the patient is approximately five years out from having completed definitive therapy for treatment …”
- 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 SCP Consult Refer denials for Cancer overturned?
In 14 California IMR decisions from 2004 to 2024, reviewers overturned 11 (78.6%). In the last five years: 66.7% of 3. 14 were medical-necessity disputes.
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.