Acute Psych/ Admit for Autism Spectrum: 61.5% of denials overturned
In 13 California IMR decisions from 2009 to 2017, reviewers overturned 8 (61.5%). 13 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 66.7% | 61.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 61.5% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric hospitalization services. Findings: The physician reviewer found that due to the persistent affective symptom complex with disordered thought processing and violent behavior in context of autism spectrum disorder, a conservative psychiatric hospital stay was to be expected. Thus, the inpatient services provided in this case were reasonably …”
“The parent of a male enrollee requested acute inpatient psychiatric hospitalization services for medical treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that a portion of the services were medically necessary for treatment of the patient’s medical condition. Early discharge would have been premature and more than likely would have resulted in undue morbidity and prompt …”
“The parent of a 19-year-old male enrollee requested inpatient hospitalization services for medical treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the patient has a systemic developmental disorder coupled with concerning cognitive impairment and disruptive behavior with prominent self-injurious behavior that dominate all domains of functionality. In reviewing the clinical documentation, the patient had not …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the acute inpatient psychiatric level of care services received. between two separate ranges of dates of service. Findings: The physician reviewer found that the patient was admitted to the inpatient unit due to anxiety issues and behavioral problems. It is noted that prior to each of …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Acute Psych/ Admit denials for Autism Spectrum overturned?
In 13 California IMR decisions from 2009 to 2017, reviewers overturned 8 (61.5%). 13 were medical-necessity disputes.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.