Diagnostic imaging & screening denials at external review

• the question matters

  The outcome turns on which question was put to the reviewer: 53.4% on medical necessity (n=672) against 40.9% on experimental/investigational (n=574) — a gap of 13 points inside the same treatment class.

• rising

  It has risen over the published record: 25.0% in 2002 against 53.6% 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 American College of Rheumatology more than any other standard here — 193 decisions, which came out at 57.0%, 9 points above the class as a whole. Citing a standard and the outcome share a cause; this is not the effect of naming it.

• concentrated

  25% of these disputes involved cancer alone (n=317, 55.8% overturned), so the headline figure for diagnostic imaging & screening is largely that pairing.

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.

• American College of Rheumatology57.0%193
• NCCN56.7%187
• American College of Cardiology31.5%54
• American Heart Association22.5%40
• FDA66.7%36
• American College of Obstetricians and Gynecologists15.2%33
• American Academy of Dermatology—13
• American Urological Association—12

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.

• Cancer55.8%317
• Orthopedic & musculoskeletal52.2%209
• Cardiac & circulatory43.3%134
• Genitourinary & kidney39.1%92
• Digestive & GI57.5%80
• CNS & neuromuscular64.1%78
• Endocrine & metabolic26.6%64
• Prevention & wellness35.9%39

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• Other56.5%168
• Breast69.6%69
• Prostate56.4%55
• Back Pain43.5%46
• Not classified35.9%39
• Melanoma10.8%37
• High Cholesterol14.3%35
• Knee Problem/Pain50.0%30

• Medical Necessity53.4%672
• Experimental/Investigational40.9%574
• 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.