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Biopsy denials: what the review data shows
Independent reviewers have decided 51 published cases where an insurer denied Biopsy — and they overturned the insurer 37.3% of the time. A denial for Biopsy is a starting position, not a final answer.
Published decisions
51
2001–2026
Overturned
37.3%
19 denials reversed
Conditions behind biopsy denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Breast | 7 | 42.9% |
| Lung | 4 | 75% |
| Thyroid Problems | 3 | 33.3% |
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 |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 35 | 31.4% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 15 | 46.7% |
Typical time to a decision
12 days
Most land between 5 and 21 days
Handled as urgent
41.2%
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
The parent of an enrollee has requested authorization and coverage for a coordinated evaluation with a team of specialists who specialize in Shwachman-Diamond Syndrome (SDS), including a SDS specialist, allergist, gastroenterologist, endocrinologist, and pulmonologist in order to obtain a current treatment plan to best manage the enrollee’s condition. The submitted documentation supports the medical necessity of the requested services. SDS is a rare autosomal recessive disorder that affects multiple organ systems, and is characterized by exocrine pancreatic insufficiency, impaired hematopoiesis, and leukemia predisposition. There may also be skeletal, immunologic, hepatic, and cardiac abnormalities. SDS is classified as a bone marrow failure syndrome, and patients with this syndrome are at increased risk of developing myelodysplasia.
Nature of Statutory Criteria/Case Summary: A 68-year-old female enrollee has requested reimbursement for the Guardant360 genetic test. The therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas (Case Study). The mutational landscape of non-small cell lung cancer has significantly expanded in the past few years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences (Case Study). Generally, KRAS, TP53, and BRAF are included in these panels and are informative (Case Study). The Guardant360 test analyzes oncogenes and tumor suppressor genes for mutations by next generation sequencing. The results can assist providers in selecting treatment towards these mutations.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for genetic cancer susceptibility panels (Guardant360 testing). The enrollee has a diagnosis of stage IV non-small cell lung carcinoma. He reported developing a dry cough that did not improve with inhalers and systemic treatment. A chest x-ray showed a large left sided mass. A computed tomography (CT) scan showed a 6.8 x 5.8 cm left lower lobe (LLL) mass extending to the hilum with mild spiculated margins and surrounding ground glass opacifications. A positron emission tomography (PET) scan confirmed a fluorodeoxyglucose (FDG)-avid 5.9 x 7.5 x 6.5 LLL mass with standardized uptake value (SUV) 19.5, FDG-positive left mediastinal and hilar nodes, a right fifth rib lesion and an L4 lesion. A CT-guided biopsy of the lung mass confirmed primary adenocarcinoma of lung with lepidic growth pattern.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate saturation biopsy for evaluation of the enrollee’s atypical prostate biopsy results. Findings: Three physician reviewers found that the biopsy revealed atypical small acinar proliferation (ASAP) at the left lateral apex. There was another follow up biopsy which revealed ASAP at the left apex. At this visit, he presented with elevated prostate specific antigen (PSA), hypogonadism and ASAP. He had a prostate cancer antigen (PCA) 3 test which was normal at 24. His PSA was up to 11.5. He had prostate magnetic resonance imaging (MRI), which was normal. A repeat MRI showed small suspicious areas central zone. However, according to the prostate image reporting and data system (PIRADS), the report indicated a score of 3, which is low suspicion for cancer.
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 treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Biopsywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
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.