Social Skills Thpy denials: 42.9% overturned by independent reviewers
In 21 California IMR decisions from 2009 to 2018, reviewers overturned the plan 9 times (42.9%). 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 |
|---|---|---|---|
| Autism Spectrum | 21 | 42.9% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 11 | 45.5% | 42.9% |
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: The parent of an enrollee has requested group social skills therapy for treatment of the enrollee’s autism spectrum disorder. Findings: The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. There is evidence that social skills groups are effective for children with autism spectrum …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy services and social skills for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Group speech therapy services and social skills are indicated to address the …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested one hour per week of social skills group training for treatment of the enrollee’s autism spectrum disorder. The physician reviewer found that the medical literature demonstrates that both ABA and social skills groups are effective for patients with autism spectrum disorder. In this case, the patient receives 15 …”
- 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 Social Skills Thpy denials overturned?
In 21 California IMR decisions from 2009 to 2018, reviewers overturned the plan 9 times (42.9%).
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.