Elevated Prostate Specific Antigen: when insurers say no, reviewers often say yes
In 19 published external-review decisions involving elevated prostate specific antigen, independent physician reviewers overturned the insurer’s denial 0% of the time.
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% |
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 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.
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 elevated prostate specific antigen 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