Psychological Evaluation denials: 33.3% overturned by independent reviewers
In 21 California IMR decisions from 2019 to 2024, reviewers overturned the plan 7 times (33.3%). In the last five years: 21.4% of 14. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Mental Disorder | 14 | 35.7% | 22.2% of 9 |
| Autism Spectrum | 5 | 0.0% | 0.0% of 4 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 7 | 0.0% |
| 2022 | 3 | 66.7% |
| 2024 | 4 | 25.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 33.3% | 33.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 6 | 0.0% | 33.3% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 0.0% | 33.3% |
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
“The physician reviewer found that the parent of the patient requested neuropsychological testing.While the patient has some concerns for attention-deficit hyperactivity disorder (ADHD) inattentive type, this diagnosis is made clinically using observation, gathering of history, and gathering of collateral information. There are no validated tests or instruments to reliably diagnose ADHD. However, in this case, the patient also has significant …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for an additional 10 units (for a total of 30 units) of neuropsychological testing services. In this case, the patient has medically and surgically refractory epilepsy, and is status post a partial resection of the right frontal lobe, with subsequent implantation of RNS. He continues to have …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for an additional 12.5 hours of neuropsychological testing (5 units CPT 96133 and 15 units of CPT 96139 for 27 total hours/41 units).Findings: The physician reviewer found that Health Plan approved 14.5 out of the 27 hours of neuropsychological testing requested. Given that the diagnosis of attention deficit hyperactivity …”
- 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 Psychological Evaluation denials overturned?
In 21 California IMR decisions from 2019 to 2024, reviewers overturned the plan 7 times (33.3%). In the last five years: 21.4% of 14.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.