Renal Kidney denials in California external review
In the California DMHC record, independent physician reviewers decided 18 published external-review cases involving renal kidneyand overturned the plan’s denial in 55.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for renal kidney
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 10 | 80% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 7 | 28.6% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan. The assessment of disease burden and therapeutic response in this patient with metastatic renal cell carcinoma is critical to her care and effective decision-making. The patient has extensive disease with soft tissue and bone lesions. She is not able to continue with contrast enhanced computed tomography (CT) imaging due to an iodine contrast allergy. CT imaging without contrast would not be useful for appropriate care of this patient. PET imaging has demonstrated effective detection of clear cell renal cancer metastases comparable or superior to contrast CT imaging.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) (CPT 78815) with computed tomography (CT) for attenuation scans. Renal cell carcinoma most commonly metastasizes to the lungs, bone, liver, and brain. Metastatic bone lesions from renal cell carcinoma are typically lytic in nature. Bone scintigraphy has limited sensitivity in diagnosing lytic bony metastases in comparison to PET/CT, which has higher sensitivity and accuracy. In the peer-reviewed medical literature, it is noted that the utility of PET/CT is limited for renal cell carcinoma.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nivolumab (Opdivo) injections (CPT code J9299) 292.5 mg intravenous (IV) every 14 days for six cycles. The patient is not eligible for U.S. Food and Drug Administration (FDA) standard approved use of Opdivo, as he has microsatellite stable disease (Smith and Desai). The FDA supports treatment with Opdivo for patients with microsatellite instability-high or mismatch repair deficient metastatic colorectal cancer that “has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan.” This patient has the standard care option of regorafenib for treatment of microsatellite stable disease. The recommendation for the combination of regorafenib with Opdivo is based on recent data from the phase 1b results of the REGONIVO trial.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for belzutifan (Welireg). Metastatic renal cell carcinoma mostly occurs sporadically and can be present as a component of von Hippel-Lindau disease (VHL). VHL is an inherited, autosomal-dominant syndrome manifested by a variety of benign and malignant tumors, including hemangioblastomas, retinal angiomas, endolymphatic sac tumors, renal cell carcinoma, pheochromocytomas, pancreatic cysts, and neuroendocrine tumors. Both surgical resection and radiation therapy have a role in the management of appropriately selected patients with sporadic tumors. According to National Comprehensive Cancer Network (NCCN) guidelines, the hypoxia inducible factor-2alpha (HIF-2alpha) inhibitor, Welireg, is an additional treatment option for patients with VHL-associated renal cell carcinoma.
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 renal kidney, 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