Ultrasound for Prevention/Good Hlth: 63.6% of denials overturned
In 11 California IMR decisions from 2004 to 2025, reviewers overturned 7 (63.6%). In the last five years: 100.0% of 3. 8 were medical-necessity disputes, 3 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2024 | 1 | 100.0% |
| 2025 | 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. | 7 | 71.4% | 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
“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 …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for automated whole breast ultrasound. As noted in the medical literature, annual screening mammography improves health outcomes for breast cancer in female patients over the age of 40. Overall, the sensitivity of screening mammography in women with non-dense breast tissue is approximately 85%. …”
“An enrollee has requested authorization and coverage for whole breast ultrasound.Findings: Two out of three physician reviewers found that the authorization and coverage for whole breast ultrasound is likely to be more beneficial for the enrollee than any available standard therapy.Although ultrasound has a role in screening for breast cancer, most of the literature involves breast ultrasound as an augmentation …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The enrollee has requested an ultrasound of both breasts. Findings: The physician reviewer found that according to the record, breast examination was within normal limits and ultrasound results were discussed. The recommendation was for a clinical breast exam every year, annual mammogram, and a genetics referral, given family history. The enrollee was to undergo genetic …”
- 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 Prevention/Good Hlth overturned?
In 11 California IMR decisions from 2004 to 2025, reviewers overturned 7 (63.6%). In the last five years: 100.0% of 3. 8 were medical-necessity disputes, 3 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.