95% overturnedAppeal outcomes · Imaging

Denied mammography: what independent reviewers actually decided

Mammography denials almost never survived independent review, and the reason is that the criteria they are measured against are unusually public.

Screening or diagnostic mammography, including tomosynthesis, billed with modality-specific codes and frequently denied for frequency, age or supplemental modality.

What the independent reviewers decided

95%

overturned by the independent reviewer

81

of 85 decisions in the corpus

Source

California DMHC independent medical review determinations, 2017-2026. Public record.

Read this as a base rate, not as your odds

These are decisions about other patients, in one state, that had already been through the plan's own internal appeal and were then sent to an outside reviewer. That population is self-selected toward disputes worth pursuing, so the rate says what happened to cases like this at that stage — not what will happen to a specific claim. It is not medical or legal advice.

Why plans deny mammography

  • The requested interval is shorter than the policy's screening frequency.
  • The patient's age falls outside the policy's screening window.
  • Tomosynthesis or a supplemental modality is denied as not necessary in addition to the base study.
  • The study is coded as screening where the clinical situation was diagnostic, or the reverse.

What actually carried the cases that won

Objective findings led, with specialty-society criteria as the authority reviewers most often relied on — a combination that explains the 95% rate. Breast-imaging criteria are published, widely adopted and specific about risk categories and supplemental imaging, so an appeal that places the patient in a defined risk category is arguing from a source the reviewer already accepts. Where a screening-versus-diagnostic coding question is the real issue, resolving that is usually the whole dispute.

What the record showedShare of overturned decisions
Objective findings were documented77%
A published guideline supported the request17%
The severity or urgency was documented1%
The diagnosis was confirmed1%

Shares are of the overturned decisions and do not sum to 100% — a single decision often rested on more than one, and some rested on none of these.

What the reviewers cited

  • Specialty-society criteria — in 17% of the overturned decisions
  • Peer-reviewed literature — in 16% of the overturned decisions
  • FDA labeling — in 7% of the overturned decisions
  • Standard of care — in 1% of the overturned decisions
  • Clinical guidelines — in 1% of the overturned decisions

mammography denials — frequently asked

Is a denied mammogram worth appealing?
95% of 85 California independent medical reviews were overturned — the second-highest rate of any procedure we track. These denials held up very poorly under neutral review.
What carries a supplemental-imaging appeal?
The risk category. Published breast-imaging criteria define when supplemental modalities are indicated by density and risk, and an appeal that documents the category is arguing on the reviewer's own ground.
Is a coding problem an appeal or a correction?
Frequently a correction. Where a diagnostic study was billed as screening, or the reverse, the faster route is to fix the claim rather than appeal the medical necessity of a study nobody disputes.

Related guides

How external review worksCO-50 — not medically necessaryExternal review by state

Source

Denial reasons and criteria are described in plain language for reference and vary by plan and policy. This page reports what independent reviewers decided in a public California dataset; it is general information, not medical, legal, or coverage advice.

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