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Colorectal Cancer Screening: when insurers say no, reviewers often say yes
In 18 published external-review decisions involving colorectal cancer screening, independent physician reviewers overturned the insurer’s denial 38.9% of the time.
Published decisions
18
2001–2026
Overturned
38.9%
7 denials reversed
Most-fought treatments for colorectal cancer screening
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Colonoscopy | 4 | 50% |
| Monitored Anesthesia Care | 3 | 0% |
| Cologuard | 3 | 66.7% |
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 |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 13 | 30.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 60% |
Typical time to a decision
21 days
Most land between 13 and 21 days
Handled as urgent
11.1%
Expedited when a delay would cause harm
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 reimbursement for Cologuard stool testing for evaluation of the enrollee, who underwent routine colon cancer screening. Findings: 2/3 of the physician reviewers found that the physician reviewer found colorectal neoplasms shed DNA in the stool. The DNA can be isolated and tested for the presence of mutations and epigenetic changes acquired during carcinogenesis. Cologuard is a second generation stool DNA test. Cologuard has been approved by the U.S. Food and Drug Administration as a screening test for colorectal carcinoma to be followed, when abnormal, by diagnostic colonoscopy. This test may be appropriate for asymptomatic patients, 50 to 84 years of age, who are at average risk for colorectal cancer. This patient is a high risk for sedated colonoscopy due to her extensive neurologic history.
Nature of Statutory Criteria/ Case Summary: The enrollee has requested coverage for CT colonoscopy. She has a history of hypothyroidism, migraines, basal cell skin cancer, pre-diabetes mellitus, osteopenia, and appendectomy. She had a sigmoidoscopy that was negative and the plan was for a repeat procedure in five years. The enrollee had a gastroenterology consult for screening colonoscopy and reported a bad reaction to anesthesia in the past with nausea, agitation and not feeling normal for more than a day. Computed tomographic (CT) colonography (also virtual colonoscopy or CT colography) is an option for colorectal cancer (CRC) screening in asymptomatic average-risk individuals, over the age of 50 years.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
The patient is a 55-year-old male who was referred by his provider for a screening colonoscopy in February 2005. The patient has no prior history of a screening colonoscopy and no prior history of a failed attempt or unsuccessful colonoscopy. The patient underwent a CT colonography (virtual colonoscopy) instead of a conventional optical colonoscopy, which revealed a normal appearing colon and two left renal calculi. At issue is whether the virtual colonoscopy was medically necessary for evaluation of the patient’s medical condition.Virtual colonoscopy represents a noninvasive test for the examination of the colonic lumen that involves the generation of both two-dimensional and three-dimensional views of the colon and rectum using data derived from computed tomography.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for virtual colonoscopy/computed tomography colonography of the abdomen and pelvis. Findings: The physician reviewer found that the American College of Radiology (ACR) guidelines for virtual colonoscopy states that the indications for a computed tomography colonography examination include “screening examination in individuals who are at average or moderate risk for developing colorectal carcinoma.” The U.S.
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 colorectal cancer screening 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.