Psychotherapy for Autism Spectrum: 62.5% of denials overturned
In 8 California IMR decisions from 2010 to 2022, reviewers overturned 5 (62.5%). In the last five years: 100.0% of 1. 8 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 100.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for weekly appointments for mental health therapy services with a trauma care specialist. 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 …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for twice a week one and one half hour psychotherapy sessions.In this case, the patient has a history of trauma, depression, anxiety, dissociative identity disorder, and autism spectrum disorder spanning decades. The submitted documentation reflects that the patient has made progress over almost 30 years of treatment which …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and for psychotherapy services and prospective authorization and coverage for unlimited 90-minute psychotherapy office visits. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on …”
And one the reviewer upheld
“A 19-year-old female enrollee requested intensive psychodynamic psychotherapy 4-5 times per week for medical treatment of her behavioral health condition. Findings: The physician reviewer found that psychodynamic therapy is not endorsed by the American Academy of Child and Adolescent Psychiatry for treatment of autism spectrum disorder, which is a highly recognizable, and often comorbid, developmental condition firmly steeped in biological …”
- 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 Psychotherapy denials for Autism Spectrum overturned?
In 8 California IMR decisions from 2010 to 2022, reviewers overturned 5 (62.5%). In the last five years: 100.0% of 1. 8 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.