Cognitive Therapy for Autism Spectrum: 60.0% of denials overturned
In 10 California IMR decisions from 2009 to 2024, reviewers overturned 6 (60.0%). In the last five years: 66.7% of 3. 7 were medical-necessity disputes, 3 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
| 2023 | 1 | 0.0% |
| 2024 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 75.0% | 60.0% |
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: The parent of the patient requested authorization and coverage for hearing therapy (therapy services provided by a psychotherapist for the treatment of sound sensitivities (tinnitus, hyperacusis, and misophonia)) provided weekly for at least 24 sessions. Tinnitus is the perception of sounds in the absence of external acoustic stimulation. The pathophysiology of tinnitus is not fully …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for one (1) hour, weekly, in-person eye movement desensitization and reprocessing (EMDR) therapy sessions. The records indicate that this patient has a history of significant trauma with mood and anxiety symptoms as well as intermittent suicidality progressing from that trauma. Although the patient’s anxiety and depression have improved …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cognitive behavioral therapy and a neuropsychological evaluation. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation and treatment of the enrollee’s autism and anxiety. A review of the record indicates that the enrollee has been diagnosed with autism …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for (1) comprehensive assessment incorporating multiple settings (e.g., home, school) by a board certified behavior analyst (BCBA), (2) cognitive behavior therapy for 60 minutes per session once a week for eight weeks, and (3) occupational therapy for one weekly 60 minute session, for 12 weeks. The submitted …”
- 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 Cognitive Therapy denials for Autism Spectrum overturned?
In 10 California IMR decisions from 2009 to 2024, reviewers overturned 6 (60.0%). In the last five years: 66.7% of 3. 7 were medical-necessity disputes, 3 experimental/investigational.
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.