Diagnostic Imaging & Screening denials in California external review
In the California DMHC record, independent physician reviewers decided 5,994 published external-review cases involving diagnostic imaging & screening and overturned the plan’s denial in 48.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
California DMHC decisions
5,994
2001–2026
Overturned
48.5%
2,907 denials reversed
By denial reason
The stated reason changes which facts, criteria, and records matter.
| Denial reason | Decisions | Overturned |
|---|---|---|
| experimental / investigational | 3,727 | 52.6% |
| medical necessity | 2,252 | 41.7% |
Within this category
Subcategories with at least 15 published decisions.
| Subcategory | Decisions | Overturned |
|---|---|---|
| MRI | 1,070 | 42.7% |
| Lab Work | 1,017 | 31.6% |
| Other | 865 | 45.4% |
| Mammography | 784 | 93.2% |
| Genetic/Genomic Test | 582 | 51.7% |
| CT Scan | 433 | 30.3% |
| PET Scan | 429 | 59.4% |
| Ultrasound | 127 | 40.9% |
| Colonoscopy/Sigmoid | 102 | 39.2% |
| Bone Density Scan | 76 | 36.8% |
| Sleep Study | 72 | 40.3% |
| Oncotype DX Assay | 61 | 47.5% |
| Allergy Testing | 60 | 10% |
| Biopsy | 51 | 37.3% |
| Heart Monitor | 44 | 25% |
| Endoscopy | 41 | 56.1% |
| Scoping Procedure | 25 | 36% |
| Psychological Evaluation | 21 | 33.3% |
| Autonomic Testing | 18 | 77.8% |
| X-Ray | 16 | 62.5% |
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 |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3,727 | 52.6% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 2,252 | 41.7% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 15 | 40% |
Typical time to a decision
20 days
Most land between 12 and 21 days
Handled as urgent
16.4%
Expedited when a delay would cause harm
Recent direction
Rising
45.8% → 49.9% 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
Physician 1The patient is a 41-year-old woman who is currently at 11 weeks gestation. She will be age 42 at the time of delivery. Her last pregnancy was in 2003. At that time, she underwent chorionic villus sampling (CVS) for prenatal diagnosis of fetal chromosomal abnormalities and unfortunately had a spontaneous miscarriage at approximately 15 weeks gestation. The patient is concerned about undergoing a CVS this pregnancy because of the bad outcome in her last pregnancy. The patient wishes to undergo integrated screening such as nuchal translucency instead of CVS to diagnose any chromosomal abnormalities in the current pregnancy. The Health Plan has denied authorization for the requested services on the basis that integrated screening is considered investigational. A screening test is used to determine if a given population is at risk for certain disease or conditions.
Physician 1The patient is a 55-year-old woman diagnosed with stage IIB (T2N1) breast cancer in June 2002. She was ultimately treated with a modified radical mastectomy and immediate reconstruction using a TRAM flap. Final pathology documented a 3cm (T2) grade III tumor with angiolymphatic invasion with 2/10 modes positive. The tumor was ER (+) PR (-) HER2/neu (-). The patient received six cycles of TAC adjuvant chemotherapy and hormonal therapy of letrozole. She also received Zometa as part of a clinical trial.In May 2004, the patient was found to have locoregional recurrence involving the supraclavicular nodal basin as well as a large chest wall recurrence with direct rib invasion. She was started on Xeloda therapy following staging studies of a CT chest and PET scan. On examination, the mass in the upper chest was noted to decrease in size and become softer.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician 1: The patient is a 19-year-old male who consulted his gastroenterologist for a second opinion regarding his diagnosis and treatment of Crohn’s disease. The disease is said to involve the terminal ileum by small bowel x-ray. The patient had previously been found to have perianal swelling, though the only note regarding the physical examination indicates a rectal exam was deferred. At the time of the second opinion the patient was taking Asacol, Flagyl, Imuran (azathioprine), and prednisone. The gastroenterologist recommended the patient undergo Prometheus-PRO-Predict TPMT Genetics testing. The Health Plan has declined coverage for this test on the basis that there is insufficient scientific evidence demonstrating how 6-MP genotype analysis will impact the patient’s management or clinical outcomes. At issue in this case is the clinical utility of TPMT testing.
Physician #1: The patient is a 47-year-old male with non-Hodgkin’s lymphoma. He has been treated with radiation and cardiotoxic chemotherapy. He developed exertional chest pain. An echo stress test was low risk positive. The provider has recommended CT coronary angiography. The Health Plan has denied authorization for the procedure on the basis that it is investigational in nature.The consulting cardiologist indicated the patient needs further evaluation. The patient has a Class IIb indication for angiography; however, the uncertainty caused by complicating cardiotoxic chemotherapy increases the usefulness of the procedure in this patient.CT coronary angiography is an emerging technology. Performed on 64-slice scanners in centers of excellence it has been shown to be equivalent to angiography in detecting proximal to mid coronary artery stenosis.
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 category of care generally, not any individual case.
How to use this in your appeal
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 diagnostic imaging & screening, 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
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.