Appld Behav Analysis for Pediatrics: 40.0% of denials overturned
In 5 California IMR decisions from 2012 to 2023, reviewers overturned 2 (40.0%). In the last five years: 33.3% of 3. 5 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
| 2023 | 2 | 50.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for an additional one hour of speech therapy (totaling two hours per week). The patient’s conditions would be benefited by the implementation of rehabilitating therapies including speech, occupational, and physical therapy if indicated. Detailed therapy can be determined by the therapist with extensive evaluation. Receptive …”
“The parent of a five-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his medical condition. Findings: The physician reviewer found that review of the submitted documentation demonstrates that the patient has had three evaluations along with a developmental history that support a diagnosis of autism spectrum disorder. The behaviors in this patient that need to be …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for applied behavior analysis (ABA) therapy. The ABA Coding Coalition lists several diagnoses for which ABA services may be medically indicated, including global developmental delay. However, a patient's diagnosis alone is insufficient to indicate treatment. The ABA Coding Coalition highlights …”
- 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 Appld Behav Analysis denials for Pediatrics overturned?
In 5 California IMR decisions from 2012 to 2023, reviewers overturned 2 (40.0%). In the last five years: 33.3% of 3. 5 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.