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Cancer Rx denials: what the review data shows
Independent reviewers have decided 145 published cases where an insurer denied Cancer Rx — and they overturned the insurer 46.2% of the time. A denial for Cancer Rx is a starting position, not a final answer.
Published decisions
145
2001–2026
Overturned
46.2%
67 denials reversed
Conditions behind cancer rx denials
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 |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 84 | 50% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 61 | 41% |
Typical time to a decision
6 days
Most land between 3 and 7 days
Handled as urgent
98.6%
Expedited when a delay would cause harm
Recent direction
Rising
34.8% → 56.6% 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
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for combination therapy of BRAFTOVI (encorafenib) and MEKTOVI (binimetinib). A researcher explains that craniopharyngiomas are rare tumors of embryonic tissue left over from human development. They occur in the brain, sometimes near the hypothalamus and optic nerves. Pathology can show infiltrative growth patterns near vital structures, precluding full surgical resection. Schweizer and colleagues note that papillary subtypes of craniopharyngiomas have the activating BRAF V600E mutation in 90% of cases. In this respect, the clinical situation resembles the rare pathologic subtypes of gliomas with BRAF mutations, such as xanthoastrocytomas.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abemaciclib (Verzenio). Researchers report, “Patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer who have received two or more previous therapies for advanced disease have few effective treatment options. The monarcHER trial aimed to compare the efficacy of abemaciclib plus trastuzumab with or without fulvestrant with standard-of-care chemotherapy of physician's choice plus trastuzumab in women with advanced breast cancer.” The authors found that at a median follow-up of 19 months, the median progression-free survival (PFS) was 8.3 months in the abemaciclib/fulvestrant/trastuzumab group, versus 5.7 months in the other two groups. Overall response rates were 33 % with abemaciclib/fulvestrant/trastuzumab, and 14 % in each of the other arms.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Exkivity (mobocertinib). The use of next-generation sequencing (NGS) panel testing as a means to select anti-cancer therapy in advanced cancer has been advancing over the past few years and is an area of active research with ongoing studies including Targeted Agent and Profiling Utilization Registry (TAPUR) and Molecular Analysis for Therapy Choice (MATCH). The concept of this approach is that all cancers are unique and that each cancer has a specific individual molecular driver which can be identified using this testing. Once identified, specific therapy can be given to the patient that directly treats their tumor.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tibsovo. The use of next-generation sequencing (NGS) panel testing as a means of selecting anti-cancer therapy in advanced cancer has been progressing over the past few years and is an area of active research with ongoing studies. The concept of this approach is that all cancers are unique and that each cancer has a specific individual molecular driver which can be identified using this testing. Once identified, specific therapy can be given to the patient that directly treats their tumor. In this case, the patient was originally diagnosed with anaplastic astrocytoma. Notes dated 6/28/22 reported that the patient had a recurrence that was categorized as glioblastoma, World Health Organization (WHO) grade IV.
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 Cancer Rxwhen 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.