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Autism Spectrum Disorder: when insurers say no, reviewers often say yes
In 1,410 published external-review decisions involving autism spectrum disorder, independent physician reviewers overturned the insurer’s denial 66.5% of the time.
Published decisions
1,410
2001–2026
Overturned
66.5%
938 denials reversed
Most-fought treatments for autism spectrum disorder
What insurers denied — and how those fights ended.
| Treatment | Decisions | Overturned |
|---|---|---|
| Applied Behavior Analysis | 506 | 69.4% |
| Speech Therapy | 344 | 75.9% |
| Occupational Therapy | 193 | 78.2% |
| Residential Treatment Center | 56 | 73.2% |
| Partial Hospitalization Program | 31 | 61.3% |
| Intensive Outpatient Program | 18 | 61.1% |
| Speech And Language Therapy | 17 | 94.1% |
| Physical Therapy | 16 | 81.2% |
| Cubby Bed | 13 | 100% |
| Applied Behavioral Analysis | 12 | 66.7% |
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. | 1,319 | 67% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 86 | 60.5% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 5 | 40% |
Typical time to a decision
20 days
Most land between 6 and 21 days
Handled as urgent
33.8%
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 authorization and coverage for readmission to residential treatment center (RTC) services for a 90-day program, or in the alterative, a 60-day program. The Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) 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. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Several studies in Child Adolescent behavior have created an instrument 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 this instrument providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use, and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for five additional units of psychological testing (12 units total). In this case, a Psychological Evaluation Report dated 4/11/24 indicated that the purpose of the psychological evaluation was to rule out autism and attention deficit hyperactivity disorder (ADHD). However, the assessment completed across both days were geared more toward assessing for ADHD, without autism-specific assessments being completed.
Nature of Statutory Criteria/Case Summary: The parents of the enrollee have requested reimbursement and prospective authorization and coverage for an additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 11/12/20 through 5/12/21.At issue in this case is whether the additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 11/12/20 through 12/31/20 were medically necessary to treat the patient’s condition. Were and/or are the additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 1/01/21 through 5/12/21 medically necessary to treat the patient’s mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A)?
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 autism spectrum disorder 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.