Speech Therapy for Cardiac/Circ Problem: 77.8% of denials overturned
In 9 California IMR decisions from 2009 to 2019, reviewers overturned 7 (77.8%). 3 were medical-necessity disputes, 6 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. | 3 | 66.7% | 77.8% |
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 speech therapy for treatment of her medical condition. Findings: Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patient’s medical condition than available standard modalities. The services at issue are supported by the medical literature in this clinical setting. Researchers assessed …”
“A male enrollee requested speech therapy for medical treatment of his medical condition status post ischemic stroke. Findings: Two physician reviewers found that there is adequate support for speech therapy in treating cognitive/linguistic deficits after cerebrovascular accidents. This patient’s documentation describes a cognitive deficit secondary to an ischemic stroke which bled, which is known as an acquired brain injury. The …”
“A 63-year-old female enrollee has requested continued speech therapy/cognitive rehabilitation services for treatment of her medical condition. Findings: Three physician reviewers found that the medical records indicate that the patient has had prior stroke, with residual deficits and impairments. The current medical literature supports the requested services in this clinical setting. The study by Wan and colleagues showed that an …”
And one the reviewer upheld
“Nature of Statutory Criteria/ Case Summary: Findings the physician reviewer found that coverage for speech therapy, three times per week at 30 minutes per session. The enrollee has a history of hypoplastic aorta syndrome, hypoplastic left heart syndrome, ventricular septal defect, and two strokes. After the second stroke, he has diagnoses of chorea, apraxia, developmental delay, and speech delay. He …”
- 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 Speech Therapy denials for Cardiac/Circ Problem overturned?
In 9 California IMR decisions from 2009 to 2019, reviewers overturned 7 (77.8%). 3 were medical-necessity disputes, 6 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.