Occupational Therapy for Mental Disorder: 73.7% of denials overturned
In 19 California IMR decisions from 2004 to 2023, reviewers overturned 14 (73.7%). In the last five years: 75.0% of 4. 14 were medical-necessity disputes, 5 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 100.0% |
| 2022 | 2 | 50.0% |
| 2023 | 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. | 7 | 42.9% | 73.7% |
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
“Nature of Statutory Criteria/Case Summary: The parents of the patient requested authorization and coverage for occupational therapy, in person, once per week.Avoidant/restrictive food intake disorder (ARFID) involves a reduction in nutritional intake resulting in failure to meet appropriate nutritional requirements, due to minimal interest in eating or food, disliking sensory characteristics of food, or fearing the potential consequences of eating …”
“The physician reviewer found that An enrollee’s parent has requested authorization and coverage for occupational therapy (sensory integrative services). The records document that this patient’s primary diagnosis is autism. As is common with most patients with autism spectrum disorder, the patient has been impacted by multisensory processing abnormalities that began early in neurodevelopment and frequently interfere with the ability to …”
“The physician reviewer found that The patient’s parent has requested authorization and coverage for occupational therapy services (twice a week). As noted in the medical literature, patients with ADHD manifest behavioral and functional impairments, as well as social and psychological issues that are problematic for participation and academic learning (Ianni, et al.). Patients in this subset also demonstrate delays or …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for occupational therapy services, once a week. The submitted documentation fails to demonstrate the medical necessity of the requested services. The in-network occupational therapist has recommended twice monthly sessions for 12 weeks to address the patient’s difficulties with self-help skills (using utensils for eating, toileting and tying …”
- 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 Mental Disorder overturned?
In 19 California IMR decisions from 2004 to 2023, reviewers overturned 14 (73.7%). In the last five years: 75.0% of 4. 14 were medical-necessity disputes, 5 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.