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Renal: when insurers say no, reviewers often say yes
In 29 published external-review decisions involving renal, independent physician reviewers overturned the insurer’s denial 41.4% of the time.
Published decisions
29
2001–2026
Overturned
41.4%
12 denials reversed
Most-fought treatments for renal
What insurers denied — and how those fights ended.
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. | 20 | 50% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 9 | 22.2% |
Typical time to a decision
8 days
Most land between 5 and 21 days
Handled as urgent
55.2%
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
A 69-year-old male has requested coverage for a positron emission tomography (PET) scan for evaluation of his renal cancer. Findings: Three physician reviewers found that the patient has undergone right nephrectomy for renal cell cancer. Prior magnetic resonance imaging (MRI) and computed tomography (CT) scans showed liver metastases which have shrunken over time with treatment. The patient has a solitary kidney with impaired function. Laboratory testing reveals that his serum creatinine level is 1.6 and glomerular filtration rate (GFR) is 43. Previous imaging with positron emission tomography/computed tomography (PET/CT) demonstrated that the liver lesions are PET avid, thus his provider has recommended repeat PET/CT to evaluate the remaining liver lesions as well as other sites for potential treatment with radiofrequency ablation (RFA).
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryosurgical ablation. Per the current high quality peer-reviewed medical literature, cryotherapy is an acceptable standard of care therapeutic modality for management of small renal cell carcinomas. Multiple studies with follow-up data exceeding five years strongly support the long-term oncologic efficacy of cryotherapy for renal cell carcinomas measuring under 3 cm. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines for management of renal cell carcinoma supports the use of ablative therapies, such as cryotherapy, for management of clinical stage T1 kidney cancers.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician 1The patient is a 55-year-old man with a history of renal cell carcinoma who underwent nephrectomy in March 2002. Prior to that time he had been diagnosed with acute myelogenous leukemia (AML), which went into remission in 2001 with chemotherapy. He has not had a relapse of his acute leukemia. In May 2003, the patient was found to have multiple lung metastases from his renal cell carcinoma. As of June 2004 these appeared to have increased in size.The patient has a fully HLA-matched sibling who has already donated allogeneic stem cells. It has been proposed that the patient be treated with non-myeloablative allogeneic stem cell transplant. The goals of this therapy would be to control his metastatic renal cell carcinoma, and presumably to provide further treatment of his AML.
The patient is a 48-year-old male who was diagnosed with metastatic renal cell cancer in January 2005. He was initially diagnosed following VATS and lung biopsy for a left pleural effusion, at which time he also underwent talc pleurodesis. His primary was identified as the right kidney and he underwent a right nephrectomy in March 2005. He was treated with systemic therapy for his metastatic disease with IL-2 and interferon, which was changed to Avastin and interferon in August 2005. The patient had a PET scan in September 2005 demonstrating uptake of the left lung, ribs, posterior neck and soft tissue adjacent to the maxilla. Treatment was then switched to sorafinib with the persistence of metastatic, though stable, disease. By report, his last PET scan revealed only a single mass in the left lung that demonstrated FDG uptake.
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 renal 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.