Psychological Evaluation for Mental Disorder: 35.7% of denials overturned
In 14 California IMR decisions from 2019 to 2024, reviewers overturned 5 (35.7%). In the last five years: 22.2% of 9. 14 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 5 | 0.0% |
| 2022 | 2 | 50.0% |
| 2024 | 2 | 50.0% |
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% | 35.7% |
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
“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 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 …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for neurological evaluation services rendered. Researchers report that, “Early identification of dyslexia is crucial to ensure that children are able to maximize their educational potential.” Researchers note that, “Comprehensive intervention services for students with comorbid ADHD and learning disabilities will require empirically supported treatment strategies that address both disorders …”
And one the reviewer upheld
“The physician reviewer found that the patient has requested authorization and coverage for an additional 42 hours of neuropsychological testing services. The American Psychological Association (APA) has established guidelines for the testing and billing of psychological and neurological assessments that include descriptions of the various CPT codes utilized during testing and how they are to be used. In this case, …”
- 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 for Mental Disorder overturned?
In 14 California IMR decisions from 2019 to 2024, reviewers overturned 5 (35.7%). In the last five years: 22.2% of 9. 14 were medical-necessity disputes.
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.