Occupational Therapy for CNS/ Neuromusc Dis: 50.0% of denials overturned
In 18 California IMR decisions from 2002 to 2017, reviewers overturned 9 (50.0%). 15 were medical-necessity disputes, 3 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 5 | 80.0% | 50.0% |
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 an enrollee has requested authorization and coverage for occupational and physical therapy at a frequency of once per week. Findings: The physician reviewer found that the medical records support the medical necessity of the requested services. A child with attention deficit/hyperactivity disorder may experience difficulties in many aspects of life, including processing …”
“The parent of a four-year-old male enrollee has requested for sensory integration therapy for treatment of the enrollee’s reported diagnosis of a sensory integration disorder. Findings: Two physician reviewers found that there is sufficient medical evidence of the efficacy of sensory integration occupational therapy in children who demonstrate deficiencies in formal testing and sensory integration therapy has a robust medical …”
“The parent of a two-year-eleven-month-old male enrollee has requested for speech therapy, occupational therapy and physical therapy for treatment of the enrollee’s multiple medical conditions. Findings: The physician reviewer found that children with speech delay can be readily treated (Law, et al.) and children with severe cognitive delays can be candidates for successful speech therapy (Goorhuis and Brower). In regards …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested continued coverage for skilled nursing facility services at a post-acute care center for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that functional impairments due to acquired brain insults such as stroke can improve with time, but are also amenable to rehabilitation interventions. The role of inpatient rehabilitative …”
- 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 CNS/ Neuromusc Dis overturned?
In 18 California IMR decisions from 2002 to 2017, reviewers overturned 9 (50.0%). 15 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.