Ultrasound for Cancer: 17.9% of denials overturned
In 28 California IMR decisions from 2003 to 2025, reviewers overturned 5 (17.9%). In the last five years: 25.0% of 16. 14 were medical-necessity disputes, 14 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 4 | 25.0% |
| 2022 | 2 | 50.0% |
| 2023 | 3 | 33.3% |
| 2024 | 5 | 0.0% |
| 2025 | 2 | 50.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 7 | 28.6% | 17.9% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 0.0% | 17.9% |
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 Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a special heart scan and laboratory test. With regard to the complete echocardiogram with Doppler flow, echocardiograms are reserved for high-risk patients after transplant. This patient is considered high risk due to a pre-existing reduced ejection fraction, graft versus host disease, and prior anthracycline …”
“The physician reviewer found that The patient has requested authorization and coverage for high-intensity focused ultrasound (HIFU). This patient has intermediate-risk prostate cancer as defined by his Gleason 4+3=7 prostate cancer. At the patient’s age, if his intermediate-risk prostate cancer is left untreated, there is a significant risk of disease progression and metastasis. HIFU is listed as an appropriate treatment …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for high intensity focused ultrasound (HIFU). The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of prostate cancer recommend HIFU as standard therapy for patients with biochemical recurrence and documented recurrent prostate cancer after radiation therapy. In this clinical setting, given the patient’s prostate-specific antigen (PSA) history, …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for high intensity focused ultrasound. The American Urological Association (AUA) guidelines for the treatment of prostate cancer note that patients with low-to-intermediate grade disease should be treated with active surveillance, radical prostatectomy, or radiotherapy. The AUA further notes that there is a lack …”
- 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 for Cancer overturned?
In 28 California IMR decisions from 2003 to 2025, reviewers overturned 5 (17.9%). In the last five years: 25.0% of 16. 14 were medical-necessity disputes, 14 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.