Ultrasound denials: 40.9% overturned by independent reviewers
In 127 California IMR decisions from 2003 to 2025, reviewers overturned the plan 52 times (40.9%). In the last five years: 56.3% of 48. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Cancer | 28 | 17.9% | 25.0% of 16 |
| Cardiac/Circ Problem | 26 | 46.2% | 87.5% of 8 |
| OB-GYN/ Pregnancy | 24 | 33.3% | — |
| GU/ Kidney Disorder | 14 | 71.4% | 77.8% of 9 |
| Prevention/Good Hlth | 11 | 63.6% | 100.0% of 3 |
| Orth/Musculoskeletal | 5 | 20.0% | 0.0% of 3 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 10 | 60.0% |
| 2022 | 7 | 71.4% |
| 2023 | 13 | 53.8% |
| 2024 | 10 | 40.0% |
| 2025 | 8 | 62.5% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 44 | 45.5% | 40.9% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 15 | 53.3% | 40.9% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 14 | 7.1% | 40.9% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 3 | 33.3% | 40.9% |
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 an enrollee has requested authorization and coverage for an automated whole breast ultrasound. Individuals with dense breast tissue are considered to be at intermediate risk for breast cancer. According to American College of Radiology guidelines, screening breast ultrasound can improve cancer detection in this population.Medical literature shows that for people with dense breast tissue, supplemental …”
“The physician reviewer found that a patient has requested authorization and coverage for an endoscopic ultrasound.The records indicate that this patient has experienced symptoms as well as low elastase consistent with exocrine pancreatic insufficiency. Exocrine pancreatic insufficiency can be caused by chronic pancreatitis, but also by pancreatic malignancy. Endoscopic ultrasound is an effective modality to diagnose, characterize, and find the …”
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an automated whole breast ultrasound. The medical literature notes that annual screening mammography improves health outcomes for breast cancer in female patients over the age of 40. The sensitivity of screening mammography in patients with non-dense breast tissue is approximately 85%. However, this is significantly decreased in …”
- 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 Ultrasound denials overturned?
In 127 California IMR decisions from 2003 to 2025, reviewers overturned the plan 52 times (40.9%). In the last five years: 56.3% of 48.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.