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Ovarian: when insurers say no, reviewers often say yes
In 104 published external-review decisions involving ovarian, independent physician reviewers overturned the insurer’s denial 51.9% of the time.
Published decisions
104
2001–2026
Overturned
51.9%
54 denials reversed
Most-fought treatments for ovarian
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Chemotherapy | 25 | 36% |
| PET Scan | 16 | 75% |
| Cancer Rx | 7 | 42.9% |
| Genetic Genomic Test | 6 | 100% |
| Lab Work | 6 | 50% |
| Investigational Tx | 6 | 50% |
| Surgery | 4 | 50% |
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. | 69 | 52.2% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 35 | 51.4% |
Typical time to a decision
7 days
Most land between 7 and 16 days
Handled as urgent
66.3%
Expedited when a delay would cause harm
Recent direction
Falling
60% → 50% 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
Physician 1The patient is a 60-year-old female who was diagnosed with stage IV ovarian cancer in October 2003. The patient presented with a malignant pleural effusion and subsequently at laparotomy was found to have carcinomatosis. The patient completed six cycles of chemotherapy and has been followed with CA-125, CT scans, and PET scans.As of 10/14/04, the patient’s CA-125 increased to 47.6, which is elevated. A CT scan performed on 9/9/04 showed increased right hydronephrosis and a borderline enlarged left axillary lymph node. A PET scan in June 2004 showed right hydronephrosis with no other abnormal areas of increased activity.
Physician 1The patient is a 53-year-old female with the diagnosis of two primary cancers, lung and ovarian. On 1/9/04, the patient had a percutaneous biopsy of a left supraclavicular mass, which showed a poorly differentiated squamous cell carcinoma, probably lung in origin. On 2/1/04, the patient underwent a total abdominal hysterectomy and a bilateral salpingo-oophorectomy (TAH-BSO), which revealed a serous cystadenocarcinoma, grade III. A positron emission tomography (PET) scan was performed on 2/24/04, which showed widespread metastatic disease involving left supraclavicular area, mediastinum, right lung, retroperitoneum, and pelvis. A CT scan was performed on 5/3/04 and was compared to the prior exam of 1/14/04. There had been the interval TAH-BSO and marked improvement in the pulmonary nodules and mediastinal and retroperitoneal adenopathy.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician 1The patient is a 49-year-old female who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy and debulking of tumor in July 2002 for ovarian cancer. In September 2002, the patient developed right upper quadrant abdominal pain. CT scan revealed two lesions in the right lobe of the liver. Biopsy was positive for metastases. Taxol and carboplatin resolved the metastases and a CT scan performed in March 2003 showed no residual tumor. In September 2003, the patient’s CA-125 began to rise and metastases were confirmed as recurrence in the liver. Gemzar was initiated and a consultation regarding radiofrequency ablation (RFA) was sought. In February 2004, the patient’s CA-125 increased to 304 from 182. The patient had discontinued chemotherapy due to toxicity. A CT of the abdomen in February 2004 revealed a 3cm mass in the liver.
Physician #1: The patient is a 53-year-old woman with ovarian cancer. She had her initial surgery in September 2004, with the findings of Stage III papillary serous ovarian cancer. She had extensive peritoneal and omental seeding as well as positive lymph nodes. She was apparently treated with chemotherapy and underwent second-look surgery in March 2005. It appears she was free of cancer at that time.Since that time she has had a rising CA-125 and a recent PET scan has demonstrated new areas of uptake consistent with recurrent cancer. She has been started on Doxil chemotherapy and has requested authorization and coverage for intraperitoneal chemotherapy. At issue is whether the requested therapy is likely to be more beneficial for treatment of the patient’s condition than any available standard therapy.Intraperitoneal chemotherapy for ovarian cancer has been studied for many years.
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 ovarian 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.