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Cancer Care denials: what the review data shows
Independent reviewers have decided 1,625 published cases where an insurer denied cancer care — and they overturned the insurer 43.6% of the time. If your denial is in this category, the odds say: appeal.
Published decisions
1,625
2001–2026
Overturned
43.6%
708 denials reversed
By denial reason
The excuse on the letter changes the odds — and the counter-strategy.
| Denial reason | Decisions | Overturned |
|---|---|---|
| experimental / investigational | 897 | 41.4% |
| medical necessity | 719 | 46.6% |
Within this category
Subcategories with at least 15 published decisions.
| Subcategory | Decisions | Overturned |
|---|---|---|
| Proton Beam | 315 | 34% |
| Other | 292 | 48.6% |
| Chemotherapy | 224 | 42.4% |
| Radiation Oncology | 150 | 38.7% |
| Radiation Therapy | 147 | 58.5% |
| Cancer Rx | 145 | 46.2% |
| Investigational Tx | 145 | 44.1% |
| Surgery | 127 | 44.9% |
| OON/ Acad Ctr Ref | 33 | 42.4% |
| Clin Trial (I) | 19 | 26.3% |
| Clin Trial (II - IV) | 18 | 50% |
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 category outcome when 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.