Elevated Prostate Specific Antigen denials in California external review
In the California DMHC record, independent physician reviewers decided 19 published external-review cases involving elevated prostate specific antigenand overturned the plan’s denial in 0%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 16 | 0% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 3 | 0% |
What the reviewers wrote
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score). This patient presents with elevated prostate specific antigen (PSA) and benign prostatic hyperplasia (BPH). The patient underwent ExoDx testing, which revealed a 91% chance of no high grade prostate cancer. As noted in the peer-reviewed medical literature, the use of ExoDx testing to forego biopsy in patients with increasing PSA and negative magnetic resonance imaging (MRI) has not been demonstrated to improve clinical patient health outcomes.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SelectMDx genomic testing provided by MDx Health, Inc. The records provided for review document that this patient has a history of elevated prostate specific antigen (PSA) and enlarged prostate. The patient underwent testing with SelectMDx genomic analysis, which demonstrated 38% likelihood of prostate cancer on biopsy, and a 13% likelihood of detecting Gleason score 7 or greater cancer. As noted in the peer-reviewed medical literature, prostate biopsy is an invasive procedure with limited risk for infection, prolonged discomfort, or urinary issues.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving elevated prostate specific antigen, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY