Cancer denials at external review

• rising

  It has risen over the published record: 36.7% in 2002 against 60.0% in 2025. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.

• most-cited standard

  Reviewers named NCCN more than any other standard here — 421 decisions, which came out at 51.1%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

• concentrated

  53% of these disputes involved cancer care alone (n=476, 52.1% overturned), so the headline figure for cancer is largely that pairing.

• high volume

  With 893 decisions in 2021-2025, this is among the five most-disputed conditiones in the published record — one of the few where the numbers are stable enough to read year by year.

California requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.

Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.

• NCCN51.1%421
• FDA44.5%119
• American Urological Association31.4%35
• American College of Rheumatology71.0%31
• American Academy of Dermatology—14
• American Society of Clinical Oncology—6
• American College of Cardiology—2
• American Heart Association—2

A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.

• Cancer Care52.1%476
• Diagnostic imaging & screening55.8%317
• Pharmacy45.2%31
• Durable medical equipment—13
• Acute inpatient medical—10
• Special procedures—9
• Diagnostic & physician evaluation—8
• Electro, thermal & radiofrequency—8

Browse all treatment classes · Pick your own pair

• Genetic/Genomic Test55.6%189
• Proton Beam51.0%155
• Cancer Rx45.3%139
• Other60.0%105
• Radiation Therapy58.6%70
• PET Scan69.8%63
• Surgery—20
• Ultrasound—16

• Medical Necessity57.8%467
• Experimental/Investigational48.1%424
• Urgent Care—2

Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.