Oppositional Defiant Disorder denials in California external review
In the California DMHC record, independent physician reviewers decided 86 published external-review cases involving oppositional defiant disorderand overturned the plan’s denial in 43%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for oppositional defiant disorder
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment | 21 | 33.3% |
| Residential Treatment Center | 16 | 56.2% |
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. | 80 | 45% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 4 | 25% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for residential treatment center (RTC) services. Findings: The physician reviewer found that 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’s parent has requested authorization and coverage for intensive family-focused therapy twice per week. 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. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Where the denial was upheld
Findings: The physician reviewer found that The patient has requested reimbursement 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. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for the residential treatment center services in the wilderness setting from 4/10/17 through 7/11/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patient’s behavioral health condition. The submitted documentation does not support the medical necessity of the services at issue. On 4/10/17, the patient presented to the wilderness program with a history of oppositional defiant disorder, parent child relational problem, sibling relational problem, and cannabis use disorder. The records noted that during treatment, the patient was cooperative, calm, and insightful into this patient’s psychological needs. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms.
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 oppositional defiant 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