Social Skills Thpy for Autism Spectrum: 42.9% of denials overturned
In 21 California IMR decisions from 2009 to 2018, reviewers overturned 9 (42.9%). 20 were medical-necessity disputes, 1 experimental/investigational.
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 …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for social skills group therapy and group speech therapy services. Findings: The physician reviewer found that based on the available documentation, the social skills group therapy and group speech therapy services provided were not and are not medically necessary for …”
- 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 for Autism Spectrum overturned?
In 21 California IMR decisions from 2009 to 2018, reviewers overturned 9 (42.9%). 20 were medical-necessity disputes, 1 experimental/investigational.
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.