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ADD: when insurers say no, reviewers often say yes
In 50 published external-review decisions involving add, independent physician reviewers overturned the insurer’s denial 38% of the time.
Published decisions
50
2001–2026
Overturned
38%
19 denials reversed
Most-fought treatments for add
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Non-FDA Approved Use | 9 | 33.3% |
| ADD ADHD Rx | 4 | 75% |
| CT Scan | 3 | 0% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 44 | 40.9% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 6 | 16.7% |
Typical time to a decision
21 days
Most land between 17 and 22 days
Handled as urgent
8%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient demonstrated symptoms of withdrawal including sweating, tremor, restlessness, and anxiety. The patient experienced intermittent tachycardia with an elevated heartrate. The patient’s symptoms of withdrawal could safely be managed at a Level 3.5 RTC setting.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
The patient is a 13-year-old male who was diagnosed with attention deficit disorder (ADD) approximately six years ago. He also has a history of vocal and motor tics as well as obsessive behavior. A SPECT scan performed on 3/18/04 demonstrated brain trauma with decreased left and right anterior pole and decreased posterior medial cerebellar profusion as well as parietal lobe dysfunction. The patient’s parent has requested reimbursement for the SPECT scan. The Health Plan has denied coverage stating the SPECT scan at issue is considered experimental.SPECT brain scans are not routine in the evaluation of attention deficit disorder. Even with the history of problems at birth and fetal distress, a SPECT scan is not used except on a research basis. The standard of care for ADD does not include SPECT scanning.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for methylphenidate HCL (Concerta) 54 mg, 90 count every 25 days, at dosage interval of four times a day. The U.S. Food and Drug Administration (FDA) approves the use of Concerta for the treatment of attention deficit hyperactivity disorder (ADHD). The FDA notes that the recommended dosage for adult patients should not exceed 72 mg/day. Researchers report, “The choice of stimulant is influenced by several factors; the most influential factor is the duration of action. Long-acting medication provides benefits long after school and work. It also increases the likelihood of once-daily dosing, thereby eliminating the need for mid-day dosing, making the treatment more private, avoiding stigma and improving adherence to medication.” Concerta is intended to be used once daily.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for add was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.