Speech Therapy for Ears/Nose/Throat: 46.2% of denials overturned
In 13 California IMR decisions from 2002 to 2022, reviewers overturned 6 (46.2%). In the last five years: 0.0% of 1. 13 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2022 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 16.7% | 46.2% |
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
“The parent of a 10 year old female enrollee has requested speech therapy for the treatment of the enrollee’s auditory processing disorder. Findings: The physician reviewer found that the American Speech-Language-Hearing Association (ASHA) broadly defines auditory as the “efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information”. Auditory processing disorder is described as a “deficit in …”
“The parents of a two-year-old male enrollee have requested for speech therapy for treatment of the enrollee’s bilateral sensioneural hearing loss and speech/language disorder. Findings: The physician reviewer found that research has shown that early intervention for children with hearing loss makes a significant difference in speech and language skills in the early school years. The highest degree of success …”
“The parents of a three-year-old male enrollee have requested for speech therapy for treatment of the enrollee’s speech delay. Findings: The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a child’s overall development and cognitive ability, and is related to school success. Identification of children at risk for developmental delay …”
And one the reviewer upheld
“The physician reviewer found that The patient’s parent has requested authorization and coverage for speech therapy services with a speech/language therapist that uses American Sign Language (ASL) as opposed to speech therapy services with an ASL interpreter. The records provided for review document that this patient presents with moderately severe hearing loss up to 4000 Hz on the left 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 Ears/Nose/Throat overturned?
In 13 California IMR decisions from 2002 to 2022, reviewers overturned 6 (46.2%). In the last five years: 0.0% of 1. 13 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.