OON Referral for Mental Disorder: 57.1% of denials overturned
In 14 California IMR decisions from 2002 to 2022, reviewers overturned 8 (57.1%). In the last five years: 100.0% of 1. 13 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 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. | 3 | 33.3% | 57.1% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 3 | 0.0% | 57.1% |
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 patient’s parent has requested authorization and coverage for individual therapy services, two times a week. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a …”
“Standard Review: A transgender male enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding a bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for the evaluation of the enrollee’s gender dysphoria. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that PHP treatment is medically necessary in this clinical setting. Based on the documentation submitted for review, the patient has a very severe case of school refusal with diagnosed generalized …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services at a facility that specializes in obsessive compulsive disorder (OCD) and that provides exposure response prevention (ERP). Findings: The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining 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 OON Referral denials for Mental Disorder overturned?
In 14 California IMR decisions from 2002 to 2022, reviewers overturned 8 (57.1%). In the last five years: 100.0% of 1. 13 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.