Nearly half of health plan coverage denials that reached independent medical review were overturned between 2019 and 2023, with significant variation by state, according to a Health Affairs study published Dec. 10.
Researchers from the University of California San Francisco analyzed publicly available IMR data from California, New York, Washington and Oregon, the four states where such data is available. The study examined 51,236 total IMR cases, with New York contributing the most (33,259) and Oregon the fewest (1,690).
IMR decisions are binding. When a denial is overturned, health plans must cover the previously denied service.
Four notes:
1. Overall, 46% of denials were overturned and 54% were upheld. IMR case volume increased 65% over the study period, from 7,685 cases in 2019 to 12,685 in 2023.
2. Overturn rates varied widely by state. The majority of denials in California were overturned, while more than two-thirds of denials in Washington were upheld. New York had the lowest overturn rate for cancer genetic testing cases.
3. The study took a closer look at genetic testing denials, identifying 1,341 cases with documented decisions. About 70% of those cases involved cancer-related tests. For cancer genetic testing, 70% of denials were upheld and 30% were overturned. Overturn rates ranged from 7.3% for melanoma testing to 54.8% for ovarian cancer testing. The researchers noted that high overturn rates may signal coverage policies that lag behind clinical evidence.
4. The authors called for all states to make IMR data publicly available, noting that fewer than 1% of patients exhaust their health plan’s appeals process, meaning the cases that reach IMR represent only a small fraction of total denials.
