RTC/ Admit for Autism Spectrum: 52.6% of denials overturned
In 19 California IMR decisions from 2011 to 2019, reviewers overturned 10 (52.6%). 19 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 100.0% | 52.6% |
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: An enrollee has requested authorization and coverage for enrollee admittance into a neuropsychiatric inpatient facility for observation and treatment. The submitted documentation supports the medical necessity of the requested services. The patient requires an evaluation done in a safe and controlled environment, by providers who are competent to assess the complications and risk of co-morbidities …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services provided for treatment of enrollee's behavioral health condition. Findings: The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential behavioral health services for treatment of the enrollee’s Asperger’s disorder and anxiety disorder. The physician reviewer found that this patient has a long history of behavior problems and his history reveals that a death in his family has caused him to decline significantly from his previous level …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center services. Recent progress notes indicate the patient is participating in a partial hospitalization program. The partial hospitalization program notes indicate that the patient has been cooperative in treatment. He has not reported suicidal or homicidal ideation while in the program. It …”
- 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 RTC/ Admit denials for Autism Spectrum overturned?
In 19 California IMR decisions from 2011 to 2019, reviewers overturned 10 (52.6%). 19 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.