SCP Consult Refer for Mental Disorder: 33.3% of denials overturned
In 12 California IMR decisions from 2002 to 2025, reviewers overturned 4 (33.3%). In the last five years: 50.0% of 4. 12 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 100.0% |
| 2023 | 1 | 100.0% |
| 2025 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a referral for an ASD assessment to treat the patient’s mental health or substance use disorder is medically necessary as defined in Health and Safety code section 1374.72(a)(3)(A).On review of the records, the patient has possible traits of ASD as evidenced by the provider’s notes. With respect …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for medication management appointments once every two weeks through 2024 and/or one hour per week of one-to-one dialectical behavior therapy (DBT). Findings: The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested a consultation with a plastic surgeon for treatment of her gender dysphoria. Findings: The physician reviewer found that review of the submitted documentation reveals that the patient is prepared for the next step of a surgical evaluation. The patient has had previous gender reassignment surgery, which demonstrates she is an appropriate …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a referral to a hypnotherapist. The patient’s symptoms of anxiety and symptoms of specific phobia of insects are severe and poorly controlled at this time. Hypnotherapy has some limited evidence for being effective in the treatment of anxiety, particularly in the setting …”
- 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 SCP Consult Refer denials for Mental Disorder overturned?
In 12 California IMR decisions from 2002 to 2025, reviewers overturned 4 (33.3%). In the last five years: 50.0% of 4. 12 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.