Occupational Therapy for Genetic Diseases: 80.0% of denials overturned
In 10 California IMR decisions from 2010 to 2018, reviewers overturned 8 (80.0%). 10 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 3 | 100.0% | 80.0% |
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 physical therapy and occupational therapy in the home setting. Findings: The physician reviewer found that Prader-Willi syndrome is a genetic disorder characterized by early feeding difficulties and failure to thrive, as well as significant hypotonia. Hypothalamic dysfunction may be the basis for short stature …”
“The parent of a two-year-old female enrollee has requested physical therapy and speech therapy for treatment of the enrollee’s Down’s syndrome. Findings: The physician reviewer found that based on review of the available records, this patient with Down’s syndrome has typical developmental delays in both motor and speech development. Gupta and colleagues conducted a controlled study of two populations of …”
“The parent of a one-year-old female enrollee has requested for physical therapy, occupational therapy, and speech therapy for treatment of the enrollee’s Down syndrome. Findings: The physician reviewer found that the use of speech therapy significantly helps these patients communicate and learn to function since they have delays in their developmental attainment of milestones. Speech and language therapy is often …”
And one the reviewer upheld
“The parent of a five-month-old female enrollee has requested occupational therapy for treatment of the enrollee’s Down syndrome. Findings: The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities that occur in greater frequency (Cohen; American Academy of Pediatrics; and Rasmussen, et al.). As a result, the prevention of secondary disability is important. Occupational …”
- 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 Genetic Diseases overturned?
In 10 California IMR decisions from 2010 to 2018, reviewers overturned 8 (80.0%). 10 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.