Surgery for Cancer: 44.4% of denials overturned
In 126 California IMR decisions from 2002 to 2026, reviewers overturned 56 (44.4%). In the last five years: 61.9% of 21. 76 were medical-necessity disputes, 44 experimental/investigational, 6 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 3 | 66.7% |
| 2022 | 5 | 60.0% |
| 2023 | 7 | 57.1% |
| 2024 | 2 | 50.0% |
| 2025 | 3 | 66.7% |
| 2026 | 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. | 27 | 33.3% | 44.4% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 11 | 54.5% | 44.4% |
| Urgent or emergencyThe findings mention urgency. | 9 | 22.2% | 44.4% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 8 | 50.0% | 44.4% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 8 | 12.5% | 44.4% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 4 | 50.0% | 44.4% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 66.7% | 44.4% |
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 laser interstitial thermal therapy (LITT) and stereotactic biopsy, aspiration, or excision of an intracranial lesion. This patient has advanced head and neck cancer that has progressed on radiation therapy and chemotherapy. It has invaded critical areas of the brain that are not amenable to surgical resection. Thus, …”
“The physician reviewer found that a patient has requested authorization and coverage for liver transplant surgery. Tumors that spread from the primary site of disease often have a long natural history, but are not generally curable even with treatment. The one possible exception would be for patients with disease that can be safely treated and surgically removed, with prior studies …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an irreversible electroporation procedure. This patient presents with intermediate risk prostate cancer, with a Gleason 3+4=7 prostate cancer based on prostate biopsy. Irreversible electroporation, a type of focal therapy for prostate cancer, is no longer considered investigational for certain types of prostate …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cryoablation surgery for breast cancer. Current evidence-based guidelines support surgical management of newly diagnosed invasive breast cancer with either mastectomy or breast-conserving surgery, depending on clinical factors. In this case, the patient has triple-negative, grade 3, stage II invasive ductal carcinoma. The …”
- 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 Surgery denials for Cancer overturned?
In 126 California IMR decisions from 2002 to 2026, reviewers overturned 56 (44.4%). In the last five years: 61.9% of 21. 76 were medical-necessity disputes, 44 experimental/investigational, 6 urgent care.
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.