Occupational Therapy for Pediatrics: 63.5% of denials overturned
In 63 California IMR decisions from 2002 to 2023, reviewers overturned 40 (63.5%). In the last five years: 33.3% of 3. 56 were medical-necessity disputes, 7 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 100.0% |
| 2023 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 12 | 58.3% | 63.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 4 | 0.0% | 63.5% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 3 | 33.3% | 63.5% |
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: An enrollee’s parent has requested reimbursement and prospective authorization and coverage for sensory integration therapy and authorization and coverage for functional activity. In a review of sensory integration therapy, researchers found moderate evidence to support the use of ASI within the scope of occupational therapy to improve performance. However, the authors noted that the results …”
“Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for occupational therapy services. The enrollee received occupational therapy on for sensory processing difficulty, motor delay, lack of coordination, difficulty with activities of daily living, and feeding difficulties. Records show the enrollee demonstrated decreased strength, decreased endurance, decreased self-care skills, and decreased safety. Records show he …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for occupational therapy services. Occupational therapy focuses on deficits in visuospatial, neurodevelopmental, and fine motor skills. This treatment modality addresses weakness of upper extremities including hands, as well as coordination deficits. The purpose and goal of occupational therapy in this patient’s case is to develop and improve …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for occupational therapy services. In this case, the patient has motor delays reported and confirmed on occupational therapy testing. However, a recent occupational therapy evaluation did not find deficiencies in self-care skills and did not recommend occupational therapy services. In order for occupational therapy services …”
- 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 Pediatrics overturned?
In 63 California IMR decisions from 2002 to 2023, reviewers overturned 40 (63.5%). In the last five years: 33.3% of 3. 56 were medical-necessity disputes, 7 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.