Speech Therapy for CNS/ Neuromusc Dis: 67.3% of denials overturned
In 52 California IMR decisions from 2002 to 2020, reviewers overturned 35 (67.3%). 47 were medical-necessity disputes, 5 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. | 10 | 60.0% | 67.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 0.0% | 67.3% |
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 patient’s parent has requested authorization and coverage for continued speech therapy. The records provided for review demonstrate that this patient has made gradual progress with speech therapy as noted during his evaluation. The American Speech-Language-Hearing Association (ASLHA) reports that, “Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which …”
“The parent of an enrollee has requested authorization and coverage for three-to-five 20-minute speech therapy sessions per week. Researchers state that childhood apraxia of speech (CAS) affects a child's ability to produce sounds and syllables precisely and consistently, and to produce words and sentences with accuracy and correct speech rhythm. They state that it is a rare condition, affecting only …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for weekly speech therapy and feeding therapy services co-administered in one session. Based on the available documentation, this patient’s condition warrants the requested speech and feeding therapy to improve the dysphagia, strengthen lingual movements, and improve jaw stabilization. Speech therapy will address the patient’s …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for one hour of speech therapy three times a week, one hour of occupational therapy three times a week, and one hour of physical therapy three times a week. The documentation does not support that this patient requires the skills of a qualified provider of speech, physical, and …”
- 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 CNS/ Neuromusc Dis overturned?
In 52 California IMR decisions from 2002 to 2020, reviewers overturned 35 (67.3%). 47 were medical-necessity disputes, 5 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.