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Positron Emission Tomography Scan denials: what the review data shows
Independent reviewers have decided 83 published cases where an insurer denied Positron Emission Tomography Scan — and they overturned the insurer 47% of the time. A denial for Positron Emission Tomography Scan is a starting position, not a final answer.
Published decisions
83
2001–2026
Overturned
47%
39 denials reversed
Conditions behind positron emission tomography scan denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Breast Cancer | 5 | 60% |
| Prostate Cancer | 4 | 50% |
| Melanoma | 3 | 66.7% |
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. | 42 | 42.9% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 41 | 51.2% |
Typical time to a decision
14 days
Most land between 6 and 21 days
Handled as urgent
43.4%
Expedited when a delay would cause harm
Recent direction
Rising
50% → 58.3% 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 60-year-old female who was diagnosed with stage IV ovarian cancer in October 2003. The patient presented with a malignant pleural effusion and subsequently at laparotomy was found to have carcinomatosis. The patient completed six cycles of chemotherapy and has been followed with CA-125, CT scans, and PET scans.As of 10/14/04, the patient’s CA-125 increased to 47.6, which is elevated. A CT scan performed on 9/9/04 showed increased right hydronephrosis and a borderline enlarged left axillary lymph node. A PET scan in June 2004 showed right hydronephrosis with no other abnormal areas of increased activity.
Nature of Statutory Criteria/Case Summary: The patient is a 59-year-old female with a history of hyperlipidemia, anxiety, and hypothyroidism who presented with a chronic cough for four months. Findings: The physician reviewer found that A chest x-ray demonstrated bilateral large perihilar masses. A computed tomography (CT) scan of the patient’s chest/abdomen/pelvis was subsequently obtained on 9/9/20, which demonstrated a large heterogeneously enhancing anterior mediastinal mass, mediastinal and right internal thoracic chain adenopathy, interlobular septal thickening in the anterior portions of both upper lobes concerning for lymphangitic spread of tumor, and a large heterogeneously enhancing pelvic mass. The patient was referred to an oncologist given the high suspicion for cancer who subsequently ordered a biopsy as well as a PET scan for further work up.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan. Researchers define traumatic brain injury (TBI) as an alteration in brain function, or other evidence of brain pathology, caused by an external force. TBI encompasses a broad range of pathologic injuries to the brain, of varying clinical severity, that result from head trauma. Researchers note that in patients with mild TBI, head computed tomography (CT) without contrast is the most appropriate examination choice. Head magnetic resonance imaging (MRI) without contrast may be sensitive in detecting intracranial injury that is occult on CT, such as subtle blood products or secondary signs of injury like edema.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a positron emission tomography (PET) scan and/or whole-body scan (WBS) with radioiodine (RAI). Thyroid cancer is the most common endocrine cancer each year in the United States with rising incidence. Conventional imaging methods used in the workup of thyroid cancer include ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI) scans which can provide important anatomic information about the thyroid and surrounding structures. CT and MRI are useful in the workup for locally advanced thyroid cancers to assess tumor extension into surrounding structures and cervical lymph node metastases.
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 Positron Emission Tomography Scanwhen 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.