ADHD denials in California external review
In the California DMHC record, independent physician reviewers decided 544 published external-review cases involving ADHDand overturned the plan’s denial in 50%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for ADHD
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 118 | 65.3% |
| Vyvanse | 26 | 61.5% |
| Intensive Outpatient Program | 25 | 88% |
| Partial Hospitalization Program | 24 | 58.3% |
| Neuropsychological Testing | 21 | 28.6% |
| Residential Treatment | 17 | 29.4% |
| Concerta | 15 | 46.7% |
| Adderall Xr | 14 | 57.1% |
| Occupational Therapy | 14 | 50% |
| Applied Behavior Analysis | 14 | 28.6% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 501 | 52.7% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 41 | 17.1% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.At issue in this case is whether the RTC services that were provided to treat the patient’s mental health or substance use disorder were medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). The American Academy of Child and Adolescent Psychiatry (AACAP) & American Association for Community Psychiatry (AACP) have unified the Child & Adolescent Level of Care Utilization System (CALOCUS) & the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the CALOCUS-CASII. This instrument is a standardized tool used to determine the intensity of services needed for children & adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical &/or developmental concerns.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center (RTC) care services for a total of 72 remaining days of a 90-day program.At issue in this case is whether the RTC care services for a total of 72 remaining days of a 90-day program are medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for (1) residential treatment center (RTC) services (2) for a minimum of at least 60 days. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (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 provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for residential treatment center (RTC) services. Researchers 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. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving ADHD, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY