Appeal win rates · California
Urology procedures: 41% of denials overturned
Only 16 decisions since 2021, so this page leads with all years since 2001. Across all years since 2001: 41% of 105.
Year by year
Show as a table
| Year | Decisions | Overturned |
|---|---|---|
| 2015 | 8 | 13% |
| 2016 | 9 | 22% |
| 2017 | 22 | 50% |
| 2018 | 9 | 44% |
| 2019 | 6 | 50% |
| 2020 | 12 | 50% |
| 2023 | 6 | 50% |
Recent decisions
The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.
Overturned Other · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for insertion of penile prosthesis; non-inflatable (semi-rigid) (CPT 54400). Based on the records provided for review, the…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for insertion of penile prosthesis; non-inflatable (semi-rigid) (CPT 54400). Based on the records provided for review, the patient likely has neurogenic and vasculogenic erectile dysfunction from diabetes mellitus and hypertension. The patient has tried and failed first- and second-line therapies for erectile dysfunction. The patient has also been treated with oral agents and injectable agents (SuperTrimix) without improvement. Per current guidelines, the patient is an appropriate candidate for placement of a penile prosthesis. Therefore, the requested insertion of penile prosthesis; non-inflatable (semi-rigid) (CPT 54400), is medically necessary for the treatment of the patient. Final Result: The reviewer determined that the requested medication is 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 reconstructive surgery, and is actively practicing. The reviewer is an expert in the treatment of the enrollee’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 MN24-42883
Upheld PTNS · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bladder pacemaker surgery. In cases of pelvic dysfunction, genitourinary pain with overactive bladder symptoms, and severe…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bladder pacemaker surgery. In cases of pelvic dysfunction, genitourinary pain with overactive bladder symptoms, and severe early bladder sensation on urodynamics first-line therapeutic options are pelvic floor therapy and medications. Absent from this patient’s clinical record is an account of pelvic floor therapy or non-invasive neuromodulation by percutaneous tibial nerve stimulation (PTNS), other transcutaneous electrical nerve stimulation (TENS) application, or use of Botox to address overactive bladder symptoms. While pelvic floor dysfunction was noted as a concern for a Botox trial, cystoscopy revealed no abnormal bladder findings that would suggest significant outlet obstruction concerning for an increased risk of urinary retention. The patient’s provider referred the patient for pelvic floor physical therapy. However, the records provided for review do not document that the patient underwent consultation for pelvic floor physical therapy. Since the records do not document first- and second-line therapies have been trialed and proven ineffective, the insertion of a sacral nerve stimulator is not indicated for the treatment of this patient. Therefore, the requested SNS neuromodulation procedures are 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’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 MN24-42437
Overturned PTNS · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS). The American Urological Association (AUA)…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS). The American Urological Association (AUA) guidelines on diagnosing and treating idiopathic overactive bladder explain, in Statements 11 through 14, that treatment of overactive bladder often follows a stepwise approach, with non-invasive/medication strategies employed first. In this case, consistent with these guidelines, the patient was first offered strategies such as pelvic floor physical therapy, behavioral modification, and bladder training. The patient did not respond to these treatments and, consistent with AUA guideline Statements 16, 20, and 21, was started on numerous oral medications. The patient did not respond sufficiently to oral medications, and she was offered third-line therapy. This is in line with AUA guideline Statement 25, which recommends that for patients with overactive bladder who have an inadequate response to or have experienced intolerable side effects from pharmacotherapy or behavioral therapy, clinicians should offer sacral neuromodulation, percutaneous tibial nerve stimulation, and/or intradetrusor botulinum toxin injection. The AUA further notes that percutaneous tibial nerve stimulation as a treatment protocol for patients with overactive bladder syndrome is supported by several studies. Given that peripheral tibial nerve stimulation is one of the mainstays of treatment for overactive bladder when medications and lifestyle modification are ineffective, the services at issue were and are medically indicated. Therefore, PTNS was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’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 MN24-42310
Overturned Other · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient with a diagnosis of benign prostatic hyperplasia (BPH) with urinary obstruction and lower urinary tract symptoms (LUTS) has requested authorization and coverage for…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient with a diagnosis of benign prostatic hyperplasia (BPH) with urinary obstruction and lower urinary tract symptoms (LUTS) has requested authorization and coverage for transurethral waterjet ablation prostate. In this case, the patient presents with a history of LUTS unresolved by three medications which caused unacceptable side effects. The current medical literature reports that eight-year results of waterjet ablation show International Prostate Symptom Score (IPSS) improvement greater than that of transurethral resection of the prostate (TURP), and demonstrate less need for early retreatment. Additionally, the side effect incidence for retrograde ejaculation is decreased over threefold. Given the available controlled trial results, waterjet ablation is more beneficial and may, with longer follow-up, replace TURP as the procedural “gold standard” for BPH treatment. All told, the requested transurethral waterjet ablation prostate is likely to be more beneficial for treatment of the patient’s condition than any available standard therapy.Findings: Three of the three physician reviewers found that the requested services are likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: Medical professional reviewer 1 is board certified in urology and is actively practicing. Medical professional reviewer 2 is board certified in urology and is actively practicing. Medical professional reviewer 3 is board certified in urology and is actively practicing. The reviewers are experts 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 EI24-42978
Upheld Other · Cancer The physician reviewer found that The patient has requested authorization and coverage for partial nephrectomy to be performed at the same time as the approved hysteroscopy with a biopsy. On review of the medical records and specifically, the urology…
The physician reviewer found that The patient has requested authorization and coverage for partial nephrectomy to be performed at the same time as the approved hysteroscopy with a biopsy. On review of the medical records and specifically, the urology consultation, the patient was found to have a 1.5 x 1.2 cm enhancing low-density, cyst in the middle of the kidney with a Bosniak 3 classification. The recommendation by the patient’s urologist was to proceed with a partial nephrectomy. The records do not demonstrate that this patient has stage 3 kidney cancer, which is defined as a spread of the tumors into regional lymph nodes. Based on the records, this patient likely has stage 1 kidney cancer, which is the lowest stage of cancer, but this can only be confirmed with pathology confirming the presence of carcinoma. This patient has a cyst which has features that indicate kidney cancer and removal is thus appropriate. Yet the decision to proceed with a partial nephrectomy is based on American Urological Association (AUA) guidelines which noted that “clinicians should prioritize partial nephrectomy for the management of the cT1a renal mass when intervention is indicated”. Since the patient’s records do not support a diagnosis of stage 3 kidney cancer, the requested partial nephrectomy is not urgent and can be performed in a separate procedure from the planned hysteroscopy with biopsy. These findings indicate that timing the partial nephrectomy at the time of planned hysteroscopy with biopsy is not supported by the current guidelines. Therefore, the requested partial nephrectomy to be performed at the same time as the approved hysteroscopy with a biopsy is not medically necessary for the treatment of this patient.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. The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’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 MN23-40216
Upheld Lithotripsy · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for prostatic artery embolization (PAE) procedure. The American Urological Association (AUA) guidelines for the treatment of BPH…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for prostatic artery embolization (PAE) procedure. The American Urological Association (AUA) guidelines for the treatment of BPH do not support the use of PAE for the routine treatment of lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH). As the benefit of PAE over risk remains unclear, PAE is not recommended outside the context of clinical trials. For a patient with bladder outlet obstruction caused by the large bladder stone, , the guidelines list treatment choices including resection of the prostate utilizing Greenlight Laser, transurethral resection of the prostate (TURP), or Holmium enucleation. Given the lack of support for the requested procedure in this clinical setting in current AUA guidelines, the requested procedure is not medically indicated. Therefore, PAE procedure is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for treatment 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 enrollee’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 MN23-39894
Overturned Other · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implantation of a hydrogel spacer. One major concern during radiation therapy to the prostate is rectal toxicity due to the…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implantation of a hydrogel spacer. One major concern during radiation therapy to the prostate is rectal toxicity due to the exposure of the adjacent rectal wall. One method of reducing rectal toxicity is to create additional space and distance within the perirectum, which is the space between the prostate and the rectum. Certain rectal dose constraints must be met during the planning phase of radiation therapy before the treatment can be safely administered. Absorbable hydrogels have been created for this purpose to be placed in the perirectal space. The gel undergoes hydrolysis and dissolves six to twelve months afterward. There is strong evidence demonstrating decreased rectal toxicity when hydrogel spacers are used in the setting of external beam radiation treatment to the prostate. In a randomized, phase III trial of patients undergoing radiation therapy for prostate cancer, researchers found a benefit in the use of a hydrogel spacer in reducing adverse effects, rectal dose, toxicity, and quality-of-life declines related to bowel and sexual side effects. In a systematic review, researchers found that hydrogel spacers also demonstrated reduced late gastrointestinal and genitourinary toxicities. The rectal V70 is one of the key dosimetric parameters a treating radiation oncologist will look at while assessing the safety of a prostate radiotherapy plan. The V70 represents the volume of the rectum receiving 70 Gy dose of radiation. This V70 parameter is defined by Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) and is a widely followed guideline within the field of radiation oncology. Higher V70 values lead to a significantly increased risk of rectal toxicity. Given that placement of a hydrogel spacer has been shown to lower the V70 parameter and thus decrease the risk of both acute and late rectal toxicity, along with increases in quality-of-life following prostate radiotherapy with placement of a hydrogel spacer, the requested service is medically indicated. Therefore, implantation of a hydrogel spacer is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for 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 enrollee’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 MN23-39556
Upheld PTNS · Kidney and urinary Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eCoin implantable subcutaneous tibial nerve neuromodulation system procedure. This patient’s medical records reviewed fail to show treatment with additional…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eCoin implantable subcutaneous tibial nerve neuromodulation system procedure. This patient’s medical records reviewed fail to show treatment with additional second-line therapies other than Myrbetriq. Thus, the patient has not been demonstrated to have failed second-line therapies. As noted in the medial literature, and guidelines from the American Urological Association (AUA), subcutaneous tibial nerve neuromodulation is considered a third-line therapy available to patients with overactive bladder who have failed first- and second-line therapies (Lightner, et al.; Kaaki, et al.). eCoin subcutaneous tibial nerve neuromodulation as a third-line intervention can be recommended as an option to Botox injections when patients have failed first- and second-line therapies. This patient’s records do not document adequate failure of second-line therapies to support an indication for treatment with eCoin subcutaneous tibial nerve neuromodulation. Therefore, requested eCoin implantable subcutaneous tibial nerve neuromodulation system procedure is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment 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 enrollee’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 MN23-38728
Overturned Other · Heart and circulation Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for varicocele embolization. Percutaneous embolization is the least invasive treatment modality to repair a varicocele. In addition, varicocele embolization allows…
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for varicocele embolization. Percutaneous embolization is the least invasive treatment modality to repair a varicocele. In addition, varicocele embolization allows for direct visualization of the veins to be ligated, which can help identify the anatomical cause of the varicocele. One study noted that a transvenous approach almost completely eliminates the risk of injury to the testicular artery. One study compared the efficacy of internal spermatic vein embolization of left varicocele versus laparoscopic high ligation. The authors concluded that the patients “who underwent sclerotherapy showed a higher technical success rate, a lower recurrence rate, fewer complications, and shorter hospitalization time compared to those treated with laparoscopic ligation.” In this case, the patient has a unilateral left-sided varicocele. The current studies show that percutaneous varicocele embolization is likely to be more beneficial for the treatment of the patient than any other treatment based on lower complication rates and superior success rates in patients with a unilateral left-sided varicocele. Therefore, the requested varicocele embolization is likely to be more beneficial for the treatment of the patient than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in urology and is actively practicing. Physician reviewer 2 is board certified in urology and is actively practicing. Physician reviewer 3 is board certified in urology and is actively practicing. The reviewers are experts in the treatment of the enrollee’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 EI23-40164
Overturned PTNS · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an implantable peripheral nerve stimulation device. One study evaluated the efficacy of percutaneous medial branch peripheral…
The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an implantable peripheral nerve stimulation device. One study evaluated the efficacy of percutaneous medial branch peripheral nerve stimulation for the treatment of patients with chronic axial low back pain who failed treatment with medications, physical therapy, and/or interventions. The study found that peripheral nerve stimulation treatment was beneficial for most patients after 14 months of treatment. Another study followed up with a survey for patients that had a 60-day peripheral nerve stimulation for a wide variety of pain conditions 3-30 months after implant. The study found that most patients had sustained relief after implant. This patient has a history of chronic left low back pain and has failed multiple treatments including physical therapy, interventions, and medications. There is sufficient evidence in the medical literature to support that peripheral nerve stimulation would be the most efficacious treatment for the patient given her current medical condition. For these reasons, an implantable peripheral nerve stimulation device is likely to be more beneficial for the treatment of the patient’s condition than any available standard therapy.Findings: Two of the three physician reviewers found that the requested device is likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the requested device is likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications:Medical professional reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Medical professional reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Medical professional reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollee’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 EI23-39867
Upheld Other · Kidney and urinary The physician reviewer found that The patient has requested authorization and coverage for removal of urethral cyst. The records provided for review document that this patient has a history of chronic pelvic pain and dyspareunia. Per Hill and Taylor, “Women…
The physician reviewer found that The patient has requested authorization and coverage for removal of urethral cyst. The records provided for review document that this patient has a history of chronic pelvic pain and dyspareunia. Per Hill and Taylor, “Women with sexual pain are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression.” The available documentation states that the patient previously underwent surgery to remove a 4 mm periurethral cyst. In addition, the patient has undergone several detailed genitourinary examinations, including some under anesthesia, by multiple providers without findings of a physical condition. The patient has requested removal of a urethral cyst. As noted in the medical literature, there are normal anatomical cysts in the vagina that produce lubrication for intercourse. Most periurethral cysts can be diagnosed by physical examination and transvaginal sonography, followed by cystourethroscopy to rule out other pathology. “Common diagnoses include vulvodynia, inadequate lubrication, vaginal atrophy, postpartum causes, pelvic floor dysfunction, endometriosis, and vaginismus” (Hill and Taylor). On review of the current medical literature and this patient’s records, the requested removal of urethral cyst is not appropriate given the lack of pathology to support an indication for surgery. Moreover, there is a lack of report that the patient has failed conservative therapies for management of these symptoms. For these reasons, the requested removal of urethral cyst is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld.
Case MN22-37896
Upheld Other · Cancer Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for prostatic artery embolization (PAE). As noted in the medical literature and American Urological Association (AUA) guidelines, the first-line therapy for the…
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for prostatic artery embolization (PAE). As noted in the medical literature and American Urological Association (AUA) guidelines, the first-line therapy for the management of patients with BPH includes medical therapy with alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors, and anticholinergic medication (Parsons, et al.). When patients fail to improve with medical management, some patients are candidates for treatment with transurethral resection of prostate (TURP). In patients with very large glands measuring more than 100 cc, as in this patient, holmium laser enucleation of prostate (HoLEP) and simple prostatectomy are recommended. There is a paucity of support in the guidelines or medical literature to support an indication for treatment with the requested PAE for this patient’s BPH. Moreover, there is a lack of trial data demonstrating improved efficacy of PAE over TURP, HoLEP, or simple prostatectomy. Furthermore, the European Association of Urology (EAU) guidelines reported that, “A multidisciplinary team approach of urologists and radiologists is mandatory as the basis for future randomized controlled trials of good quality with long-term follow-up in order to integrate this treatment option into the spectrum of efficient minimally invasive treatment options.” All told, the requested PAE is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment 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 enrollee’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 MN22-37638
What these numbers mean
- These are decisions by independent doctors in California’s Independent Medical Review, run by the Department of Managed Health Care for the plans it regulates. They show how past denials ended, not the odds for any one case.
- “Overturned” means the reviewer sided with the patient and the plan had to cover the care. Only denials that reached independent review are counted.
- Plans in other states, and self-funded employer plans, use other independent reviewers; their results aren’t in this data.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, California Health and Human Services Open Data Portal, updated June 1, 2026. 42,749 decisions from 2001 to 2026 (2026 partial).