Occupational Therapy for Cardiac/Circ Problem: 50.0% of denials overturned
In 8 California IMR decisions from 2002 to 2024, reviewers overturned 4 (50.0%). In the last five years: 66.7% of 3. 7 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
| 2023 | 1 | 100.0% |
| 2024 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for skilled nursing facility (SNF) services including physical therapy (PT) for 5 days/week x 1 hour/day until the enrollee is able to self-transfer to a wheelchair and wheels himself around, is able to self-transfer to a shower chair (and back to another chair), be …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for an additional two days per week of adult day services (community-based adult services) for five days per week total.Adult day service (ADS) attendance can benefit the patient, who is typically experiencing physical and/or cognitive frailty resulting from dementia, hypertension, or physical disability. The …”
“A 54-year-old male enrollee has requested skilled nursing facility (SNF) services or in the alternative, outpatient physical, occupational, and speech therapies for treatment of his medical condition status post multiple ischemic strokes. Findings: The physician reviewer found that with regard to the skilled nursing visits from the date of service at issue onward, the patient did not have ongoing medical …”
And one the reviewer upheld
“The physician reviewer found that The patient has requested authorization and coverage for physical therapy, occupational therapy, and speech therapy provided at a skilled nursing facility (SNF). Functional impairments due to a cerebral stroke can be severe to profound. Functional recovery may be amenable to natural recovery processes and rehabilitative measures. However, the extent of initial injury generally determines the …”
- 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 Cardiac/Circ Problem overturned?
In 8 California IMR decisions from 2002 to 2024, reviewers overturned 4 (50.0%). In the last five years: 66.7% of 3. 7 were medical-necessity disputes, 1 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.