OON Referral for Pediatrics: 20.0% of denials overturned
In 10 California IMR decisions from 2002 to 2023, reviewers overturned 2 (20.0%). In the last five years: 0.0% of 1. 9 were medical-necessity disputes, 1 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 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. | 3 | 0.0% | 20.0% |
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 reimbursement and prospective authorization and coverage for occupational therapy services from an occupational therapist located within approximately 5 miles or 10 minutes from his residence for treatment of the enrollee’s gross motor delays. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the …”
“The parent of an eight-year-old female enrollee has requested a consultation with a clinical audiologist for the evaluation of the enrollee for possible central auditory processing disorder (CAPD). Findings: The physician reviewer found that in order to determine if the patient does have an auditory processing disorder, she will need to be evaluated by a licensed clinical audiologist with expertise …”
And one the reviewer upheld
“The physician reviewer found that The parent of an enrollee has requested authorization and coverage for blood tests.This patient presented to the provider with a history of food allergies. The provider has recommended a large range of laboratory testing as part of the ongoing oral immunotherapy (OIT). However, there is a lack of support for this panel, which has not …”
- 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 Pediatrics overturned?
In 10 California IMR decisions from 2002 to 2023, reviewers overturned 2 (20.0%). In the last five years: 0.0% of 1. 9 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.