Speech Therapy for Trauma/ Injuries: 50.0% of denials overturned
In 6 California IMR decisions from 2003 to 2021, reviewers overturned 3 (50.0%). In the last five years: 0.0% of 1. 4 were medical-necessity disputes, 2 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“A 47-year-old male enrollee has requested speech therapy for treatment of his brain injury. Findings: Two physician reviewers found that the services that were provided to this patient appear to have utilized cognitive rehabilitation techniques as they were intended to address the patient’s short term memory deficits, decreased executive function and deficits in attention and concentration. The provider indicated that …”
“The parent of a 10-year-old male enrollee has requested for speech therapy for treatment of his speech disorder subsequent to head trauma. Findings: The physician reviewer found that complex concussions involve cognitive impairment, such as poor attention or concentration, memory dysfunction, irritability, anxiety, depressed mood, sleep disturbance, persistent low-grade headache, lightheadedness, and sensitivity to light or sound. The term “post-concussive …”
“A 23-year-old male enrollee has requested cognitive rehabilitation/speech therapy for the treatment of his traumatic brain injury. Findings: Three physician reviewers found that the patient suffered a very severe traumatic brain injury and as a result he has significant cognitive deficits including word retrieval, processing, attention, and memory. Cognitive remediation by a speech therapist is standard therapy at most, if …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for outpatient vestibular (physical therapy) twice a week for eight weeks (CPT 97163 – physical therapy evaluation high complex; 97162 – physical therapy evaluation mod complex; 97110 – therapeutic exercises (including ROM, flexibility, endurance); 97112 – neuromuscular re-education)); and outpatient speech therapy (cognitive speech therapy) twice a week …”
- 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 Trauma/ Injuries overturned?
In 6 California IMR decisions from 2003 to 2021, reviewers overturned 3 (50.0%). In the last five years: 0.0% of 1. 4 were medical-necessity disputes, 2 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.