Decisiondx-melanoma Genetic Testing denials in California external review
In the California DMHC record, independent physician reviewers decided 12 published external-review cases involving Decisiondx-melanoma Genetic Testingand overturned the plan’s denial in 0%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Decisiondx-melanoma Genetic Testing denials
| Category | Decisions | Overturned |
|---|---|---|
| Melanoma | 8 | 0% |
| Cutaneous Melanoma | 3 | 0% |
What the reviewers wrote
Where the denial was upheld
Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for DecisionDx – Melanoma genetic testing. The enrollee was diagnosed with cutaneous melanoma after a biopsy of a lesion on his left lateral mid-back. The DecisionDx–Melanoma genetic testing report noted it was Class 1, subclass 1A. The enrollee’s dermatologist believes the results from the DecisionDx–Melanoma testing, in conjunction with other clinical assessments, help identify a person’s risk profile, which aids in optimal treatment planning. Literature describes the DecisionDx-Melanoma gene panel as a diagnostic not currently recommended by professional societies as part of standard treatment. This diagnostic requires additional analysis and research regarding the sensitivity and specificity of the test, conducted in individuals who are representative of the general primary melanoma population.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDX-Melanoma genetic testing. The service at issue is not approved by the U.S. Food and Drug Administration (FDA) for the staging or treatment of melanoma. Current medical literature does not demonstrate the clinical utility, appropriate use, or improved outcomes for melanoma patients with the use of the service at issue, and there is insufficient evidence to confirm its reliability or improved outcomes in the staging or treatment of melanoma. Traditional pathologic factors remain the strongest independent predictors of recurrence risk. In the setting of this patient’s thin melanoma, standard therapy is a wide local excision followed by periodic skin examination.
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 treatment 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 Decisiondx-melanoma Genetic Testing, 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