Cholesterol Screen denials: what the review data shows
Independent reviewers have decided 13 published cases where an insurer denied Cholesterol Screen — and they overturned the insurer 0% of the time. A denial for Cholesterol Screen is a starting position, not a final answer.
Conditions behind cholesterol screen denials
| Category | Decisions | Overturned |
|---|---|---|
| High Cholesterol | 3 | 0% |
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for cardiac marker laboratory testing for the stated condition of family history of high cholesterol. The American College of Cardiology (ACC) as well as the American Heart Association (AHA) guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), lipoprotein(b), C-reactive protein, high sensitivity CRP, insulin, insulin resistance, fibrinogen, genetic testing, and homocysteine.
Findings: The physician reviewer found that the patient requested reimbursement for Apolipoprotein testing. The American College of Cardiology (ACC) as well as the American Heart Association (AHA) guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), lipoprotein(b), C-reactive protein, high sensitivity CRP, insulin, insulin resistance, fibrinogen, genetic testing, and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.
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.
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 Cholesterol Screenwhen 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