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Metastatic Colorectal Cancer: when insurers say no, reviewers often say yes
In 22 published external-review decisions involving metastatic colorectal cancer, independent physician reviewers overturned the insurer’s denial 59.1% of the time.
Published decisions
22
2001–2026
Overturned
59.1%
13 denials reversed
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. | 13 | 76.9% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 9 | 33.3% |
Typical time to a decision
13 days
Most land between 5 and 22 days
Handled as urgent
45.5%
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 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.
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Lonsurf (trifluridine/tipiracil) tablets. This patient has advanced metastatic colon cancer. Therapeutic options include fluoropyrimidine-based combination chemotherapy regimens with monoclonal antibodies such as bevacizumab, cetuximab, or panitumumab. Lonsurf is indicated for the treatment of patients with metastatic colorectal cancer who have previously been treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, and anti-vascular endothelial growth factor (VEGF) biological therapy, and if wild-type RAS, anti-epidermal growth factor receptor (EGFR) therapy. In this case, the records reflect that the patient opted out of chemotherapy. The patient’s oncologist prescribed Lonsurf in combination with Avastin.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Guardant360 CDx test. Liquid biopsy for next generation sequencing is reserved for patients when there is insufficient tissue at biopsy or in the event of recurrence (Olson; Bettegowda, et al.). Cells from tumor are detected in the blood and used for sequencing, but there is a risk of sequencing normal tissue. This patient presented with a diagnosis of metastatic colorectal cancer. The patient’s provider recommended analysis with Guardant360 CDx testing. When this patient underwent liquid biopsy with Guardant360 CDx test, there was a lack of evidence of disease on imaging on positron emission tomography (PET) or computed tomography (CT) scan to support an indication for additional testing.
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 metastatic colorectal cancer 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.