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Diagnostic Imaging & Screening denials: what the review data shows
Independent reviewers have decided 5,994 published cases where an insurer denied diagnostic imaging & screening — and they overturned the insurer 48.5% of the time. If your denial is in this category, the odds say: appeal.
Published decisions
5,994
2001–2026
Overturned
48.5%
2,907 denials reversed
By denial reason
The excuse on the letter changes the odds — and the counter-strategy.
| 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% |
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.