Autistic Disorder denials in California external review
In the California DMHC record, independent physician reviewers decided 419 published external-review cases involving autistic disorderand overturned the plan’s denial in 61.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for autistic disorder
| Category | Decisions | Overturned |
|---|---|---|
| Appld Behav Analysis | 124 | 53.2% |
| Speech Therapy | 71 | 64.8% |
| Occupational Therapy | 34 | 50% |
| RTC | 29 | 89.7% |
| Special Bed | 27 | 85.2% |
| Partial Hospital | 12 | 66.7% |
| Intensive Outpt Prog | 10 | 70% |
| Genetic Genomic Test | 9 | 77.8% |
| Speech Generate Device | 8 | 87.5% |
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. | 404 | 61.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 14 | 57.1% |
What the reviewers wrote
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
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 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 autistic disorder, 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