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Colon: when insurers say no, reviewers often say yes
In 180 published external-review decisions involving colon, independent physician reviewers overturned the insurer’s denial 40% of the time.
Published decisions
180
2001–2026
Overturned
40%
72 denials reversed
Most-fought treatments for colon
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Chemotherapy | 22 | 36.4% |
| Genetic Genomic Test | 19 | 63.2% |
| Lab Work | 15 | 33.3% |
| PET Scan | 12 | 50% |
| Oncotype DX Assay | 9 | 33.3% |
| Investigational Tx | 9 | 33.3% |
| Radiation Oncology | 8 | 62.5% |
| Radiation Therapy | 7 | 57.1% |
| Colonoscopy Sigmoid | 7 | 14.3% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 107 | 37.4% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 73 | 43.8% |
Typical time to a decision
8 days
Most land between 5 and 21 days
Handled as urgent
52.8%
Expedited when a delay would cause harm
Recent direction
Rising
31.6% → 74.2% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and reimbursement for Guardant360 CDx liquid biopsy genetic testing. Mutated KRAS and BRAF genes are predictive markers of worse outcomes in metastatic colorectal cancer (mCRC) and have poor prognosis with anti- epidermal growth factor receptor (EGFR) therapies. Other relevant mutations to guide mCRC-treatment regimens include HER2 and NTRK fusions. In this case, notes reported that as Guardant360 CDx liquid biopsy genetic testing resulted in a finding of a KRAS mutation, the patient was not a candidate for anti-EGFR therapies, and was thus started on folinic acid, fluorouracil, and irinotecan (FOLFIRI) chemotherapy with bevacizumab, a vascular endothelial growth factor (VEGF) anti-angiogenesis antibody which does not rely on a predictive biomarker/tumor agnostic.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx comprehensive genomic profiling test. Genetic or mutational testing is informative for patients with metastatic colorectal cancer since it can help direct therapeutic decisions. Knowledge of tumor mutations figures prominently in the work-up of metastatic colon cancer in the NCCN guidelines. Specifically, KRAS and BRAF mutations may inform therapy decisions. KRAS is one of the most frequently mutated oncogenes in colorectal cancer. A mutation in KRAS has been associated with worse progression-free survival (PFS) compared to patients with wild type KRAS when treated with monoclonal antibody directed against epidermal growth factor receptor (EGFR) in combination with chemotherapy.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician #1: The patient is a 54-year-old male who presented with rectal bleeding in May 2004. He was found to have a 5.0cm circumferential rectal cancer. The CT scan showed a 3.5cm lesion in the liver which was positive on PET scan leading to a diagnosis of stage IV adenocarcinoma of the rectum. He was treated with chemotherapy (FOLFOX plus Avastin) and had a resection of his rectal carcinoma. There was a second operation with resection of his liver metastases and a second round of chemotherapy (FOLFOX) and radiation. A CT scan in July 2005 showed a mass in the right lung. A repeat CT scan and a PET scan showed three nodules in the right lung and one nodule in the left lung. In October 2005 the patient underwent right lower lobectomy and resection of the right middle lobe nodule. The pathology report showed metastatic adenocarcinoma in each specimen.
Physician 1: This patient is a 50-year-old woman first diagnosed with colon cancer in 2003. At that time she had positive lymph nodes and was treated with chemotherapy, the Folfox-4 regimen. In May 2005 she was found to have recurrent disease, and she was started on Folfiri with Avastin. She elected to stop this treatment and sought treatment with an out-of-network provider who offered her low dose chemotherapy and insulin potentiation therapy. The Health Plan has denied coverage for this therapy on the basis it is considered experimental for the treatment of colon cancer.Insulin potentiation therapy is an unproven treatment for cancer. It consists of giving insulin in a method that supposedly makes the cancer cells susceptible to lower doses of chemotherapy. The chemotherapy drugs used are a variety of standard chemotherapy drugs.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for colon was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.