Imaging, scans and lab tests: 47% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2026 · Medical necessity · age 41–50 Imaging spine pelvis · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for magnetic resonance imaging of the pelvis. The patient presents with suspected hamstring injury and possible tendonitis or bursitis, conditions for which MRI of the…

   The physician reviewer found that a patient has requested authorization and coverage for magnetic resonance imaging of the pelvis. The patient presents with suspected hamstring injury and possible tendonitis or bursitis, conditions for which MRI of the hip—not the pelvis—is the appropriate diagnostic study. Therefore, the requested MRI of the pelvis is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46983

2. Overturned 2026 · Medical necessity · age 41–50 ONC stereotactic tmt delivery · Cancer The physician reviewer found that a patient has requested authorization and coverage for proton beam radiation therapy. Proton therapy has unique physical properties that may reduce radiation exposure to surrounding normal tissues in select head and neck…

   The physician reviewer found that a patient has requested authorization and coverage for proton beam radiation therapy. Proton therapy has unique physical properties that may reduce radiation exposure to surrounding normal tissues in select head and neck cancers. Medical literature supports its use when conventional radiation may not adequately spare nearby critical structures. Given the treatment site and the patient’s head and neck anatomy, proton beam therapy is indicated to optimally treat this patient. Therefore, the requested proton beam radiation therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46954

3. Overturned 2026 · Medical necessity · age 31–40 NM gastrointestinal system · Digestive system The physician reviewer found that a patient has requested authorization and coverage for a repeat hepatobiliary iminodiacetic acid (HIDA) scan, repeat magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography…

   The physician reviewer found that a patient has requested authorization and coverage for a repeat hepatobiliary iminodiacetic acid (HIDA) scan, repeat magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP) to assess sphincter dysfunction. The patient had a cholecystectomy with a subsequent elevation in transaminases, along with abdominal symptoms that may be consistent with early postcholecystectomy syndrome. Possible underlying causes include retained stone, bile duct injury, bile leakage, biliary dyskinesia, or other biliary conditions. Evaluation for this range of potential postcholecystectomy complications supports the use of a HIDA scan and MRCP. Additionally, with elevated liver enzymes and abdominal pain, a biliary functional disorder is possible, and ERCP is appropriate to further evaluate for functional or structural abnormalities. Therefore, the requested repeat HIDA scan, repeat MRCP, and ERCP to assess sphincter dysfunction are medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested imaging is medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46908

4. Overturned 2026 · Medical necessity · age 21–30 Imaging lower extremities · Bones, joints and muscles The physician reviewer found that a patient has requested reimbursement for magnetic resonance imaging (MRI) of the knees. The American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain in an adult with initial…

   The physician reviewer found that a patient has requested reimbursement for magnetic resonance imaging (MRI) of the knees. The American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain in an adult with initial radiographs demonstrating degenerative changes indicate that MRI may be appropriate as the next imaging examination. MRI is more sensitive than radiographs for evaluating soft tissues around the knee. In this case, cartilage damage or soft tissue injury was suspected following orthopedic evaluation. The results of the MRI could affect the clinical management of whether the patient required surgery. Given that MRI was the best test for diagnosing a meniscal tear or other soft‑tissue injury, such as cartilage damage, MRI of the knees was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46890

5. Upheld 2026 · Medical necessity · age 65+ Other diag NM proc · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for prostate-specific membrane antigen positron emission tomography scan. In this case, the patient has a very slow…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for prostate-specific membrane antigen positron emission tomography scan. In this case, the patient has a very slow prostate-specific antigen (PSA) doubling time and a PSA of 1.77 ng/mL. The patient’s PSA trend does not indicate doubling of the PSA in less than six month intervals. The patient’s PSA has gone from 1.0 ng/mL to 1.77 ng/mL, indicating a less than 0.25 ng/mL rise per year. Given the patient’s very slow PSA doubling time, the patient can be treated with luteinizing hormone-releasing hormone and/or antiandrogen therapy if there are positive findings on bone scan. Overall, the medical literature and submitted records do not support the use of prostate-specific membrane antigen positron emission tomography scan in this patient’s clinical setting. Therefore, the requested prostate-specific membrane antigen positron emission tomography scan is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in urology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46876

6. Upheld 2026 · Medical necessity · age 31–40 Molecular path tier 1 and 2 · Pregnancy Childbirth The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for genetic tests: MECP2 gene analysis, molecular pathology procedure, and Noonan Spectrum disorders genetic sequencing provided. In this case…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for genetic tests: MECP2 gene analysis, molecular pathology procedure, and Noonan Spectrum disorders genetic sequencing provided. In this case, the patient was at an advanced maternal age at conception and achieved pregnancy through in vitro fertilization (IVF). The record indicates that the patient’s ultrasound showed a fetus with normal fetal heart tones (FHTs) and cervical length. There were no other abnormal ultrasound findings or concerns regarding the patient’s family history. Overall, due to the fact that there were no documented abnormalities on ultrasound or family history concerning aneuploidy, the performed extended panels were not medically appropriate in this clinical setting. As such, the genetic tests: MECP2 gene analysis, molecular pathology procedure, and Noonan Spectrum disorders genetic sequencing, were not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services were not medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with a subspecialty certification in maternal and fetal medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46864

7. Overturned 2026 · Medical necessity · age 65+ Imaging chest · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for computed tomography scan of the thorax chest and computed tomography scan of the abdomen and pelvis. The National Comprehensive…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for computed tomography scan of the thorax chest and computed tomography scan of the abdomen and pelvis. The National Comprehensive Cancer Network (NCCN) guidelines on the management of breast cancer note that computed tomography of the chest/abdomen/pelvis with contrast should be performed at baseline prior to new therapy, then every two to four cycles for patients receiving chemotherapy or targeted therapy. Per the medical records, the patient has a history of stage IV breast cancer. Given that monitoring stage IV breast cancer to assess disease progression and determine appropriate medical therapy moving forward is supported by multiple sets of expert guidelines, computed tomography scan of the thorax chest and computed tomography scan of the abdomen and pelvis are medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in hematology and medical oncology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46850

8. Overturned 2026 · Medical necessity · age 41–50 Imaging lower extremities · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for magnetic resonance imaging of the right knee. The American College of Radiology (ACR) appropriateness criteria for the evaluation of knee…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for magnetic resonance imaging of the right knee. The American College of Radiology (ACR) appropriateness criteria for the evaluation of knee pain note that, in patients with a history of prior knee surgery/ligament reconstruction, magnetic resonance imaging is usually considered appropriate. Magnetic resonance imaging can evaluate the condition of the prior ligament repair/graft and the need for revision surgery. Per the medical records, the patient has knee pain with a history of right anterior cruciate ligament (ACL) reconstruction. In this clinical setting, given that clinical management would be affected by magnetic resonance imaging results, magnetic resonance imaging of the right knee was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46840

9. Overturned 2026 · Medical necessity · age 51–64 Imaging abdomen · Sym/Sign Ab Find The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for computed tomography of the abdomen. According to the American College of Radiology appropriateness criteria for the evaluation of abdominal…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for computed tomography of the abdomen. According to the American College of Radiology appropriateness criteria for the evaluation of abdominal pain, contrast-enhanced computed tomography of the abdomen and pelvis is usually appropriate. In the setting of acute/subacute abdominal pain, the range of pathology is broad and includes gastrointestinal, biliary, pulmonary and genitourinary pathology. Imaging plays a key role in this setting to help direct patient management and treatment. In this case, the patient had a history of flank pain. A colonoscopy was recommended to evaluate the patient’s pain due to a prior computed tomography finding of colitis versus contained colonic perforation. Computed tomography of the abdomen and pelvis is the optimal test to evaluate for perforation. Colonoscopy is contraindicated in the setting of perforation. Computed tomography could have changed this patient’s management and was therefore indicated. For these reasons, the computed tomography of the abdomen was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46822

10. Upheld 2026 · Medical necessity · age 51–64 ONC proton beam tmt delivery · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for proton beam radiation therapy.The patient was appropriately recommended a course of radiation therapy and ADT as a treatment…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for proton beam radiation therapy.The patient was appropriately recommended a course of radiation therapy and ADT as a treatment modality for his high-risk prostate cancer per National Comprehensive Cancer Network (NCCN) guidelines. However, the utilization of proton beam as the radiation modality for prostate cancer remains an area of debate. A proton beam has unique properties compared to a photon or X-ray beam in its ability to deposit radiation dose. Proton therapy is strongly indicated in settings where severe toxicities would result if normal tissue constraints cannot be met by a photon beam. In the setting of localized prostate cancer, there has not been a demonstrable clinically significant improvement in quality of life or reduction of high-grade toxicities. Proton therapy may be appropriate in some cases of unusual anatomy or in cases of re-irradiation of adjacent tissues. In this patient’s clinical setting, there is no documentation of unusual anatomy or previous radiation in the area to be treated. Volumetric modulated arc therapy (VMAT) is a radiation technique frequently utilized to achieve clinically equivalent normal organ dose constraints as a proton beam. Excellent dose toxicity outcomes have been demonstrated for standard VMAT in patients with prostate cancer. Given these findings, the requested proton beam radiation therapy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46799

11. Upheld 2026 · Medical necessity · age 51–64 Imaging upper extremities · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an arthrographic examination.American College of Radiology appropriateness criteria for evaluation of shoulder pain indicate…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an arthrographic examination.American College of Radiology appropriateness criteria for evaluation of shoulder pain indicate that magnetic resonance arthrography may be appropriate when a labral tear is suspected and findings on standard radiographs and conventional magnetic resonance imaging are indeterminate. In cases where a labral tear cannot be adequately characterized on nonarthrographic magnetic resonance imaging, intra-articular contrast arthrography may provide additional diagnostic value.In this case, the records indicate that anterior and posterior labral tears were identified on standard magnetic resonance imaging of the shoulder. Because the diagnosis was established on nonarthrographic imaging, the records do not demonstrate that additional arthrographic examination would provide clinically meaningful diagnostic benefit.Given these findings, the requested arthrographic examination is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the evaluation of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46741

12. Upheld 2026 · Medical necessity · age 41–50 Other diag NM proc · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for single‑photon emission computed tomography (CT) of the cervical spine. The American College of Radiology (ACR) appropriateness criteria do not recommend single‑photon…

    The physician reviewer found that a patient has requested authorization and coverage for single‑photon emission computed tomography (CT) of the cervical spine. The American College of Radiology (ACR) appropriateness criteria do not recommend single‑photon emission CT for chronic neck pain or degenerative cervical spine conditions due to insufficient evidence that it improves diagnostic accuracy or influences clinical management. The medical records document chronic neck pain and cervical spondylosis, and the patient has already undergone extensive conservative and interventional treatments. However, current medical literature does not support the use of single‑photon emission CT imaging as providing clinically actionable information in this context. Accordingly, single‑photon emission CT of the cervical spine is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in interventional radiology and diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46645