Occupational Therapy for Autism Spectrum: 69.7% of denials overturned
In 142 California IMR decisions from 2002 to 2025, reviewers overturned 99 (69.7%). In the last five years: 45.2% of 31. 128 were medical-necessity disputes, 14 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 5 | 60.0% |
| 2022 | 2 | 0.0% |
| 2023 | 7 | 71.4% |
| 2024 | 9 | 44.4% |
| 2025 | 8 | 25.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 50 | 66.0% | 69.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 16.7% | 69.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 4 | 75.0% | 69.7% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 3 | 66.7% | 69.7% |
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
“The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient’s parent has requested authorization and coverage for occupational therapy services. Occupational therapy is indicated for patients with developmental conditions when there are functional impairments affecting daily activities and a need for skilled therapeutic intervention. Clinical guidelines support structured therapy to improve functional skills, adaptive behaviors, and overall participation in …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for occupational therapy (OT). OT treatment is supported by peer-reviewed published scientific evidence for children with autism. OT is known to be effective in improving functional outcomes for patients with autism. In this case, the patient presents with autism that …”
“Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for occupational therapy. Occupational therapy is a recommended treatment for children with autism and other developmental disabilities. Occupational therapy is known to be effective in improving functional outcomes for patients with autism-related deficits. Occupational therapy services can help treat fine motor skill deficits, behavioral functioning, …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for occupational therapy (OT) and/or an augmentative and alternative communication (AAC) device. In this case, the patient underwent a formal OT evaluation, and OT was not recommended. Thus, there is no formal OT evaluation recommending the requested OT services. Further, …”
- 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 Occupational Therapy denials for Autism Spectrum overturned?
In 142 California IMR decisions from 2002 to 2025, reviewers overturned 99 (69.7%). In the last five years: 45.2% of 31. 128 were medical-necessity disputes, 14 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.