Autism-Related Treatment denials in California external review
In the California DMHC record, independent physician reviewers decided 1,040 published external-review cases involving autism-related treatment and overturned the plan’s denial in 69.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By denial reason
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 980 | 70.2% |
| experimental / investigational | 58 | 60.3% |
Within this category
| Subcategory | Decisions | Overturned |
|---|---|---|
| Appld Behav Analysis | 470 | 69.1% |
| Speech Therapy | 301 | 79.1% |
| Occupational Therapy | 117 | 76.1% |
| Other | 46 | 37% |
| Social Skills Thpy | 21 | 42.9% |
| Partial Hospital | 15 | 46.7% |
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. | 980 | 70.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 58 | 60.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for ongoing psychotherapy treatment, every two weeks. 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 patient’s parent has requested (ABA) nine hours of behavior identification assessment by clinician for a total of 15 hours per six months; three hours of behavior identification supporting assessment by technician for total of five hours per six months; and ten hours per week adaptive behavior treatment by protocol by technician for a total for 40 hours week. The ABA Coding Coalition describes comprehensive treatment as appropriate for patients who engage in harmful and risky behaviors and/or have substantial deficits in adaptive skills that jeopardize their health and safety. Comprehensive programs often involve 30 to 40 hours of service weekly, plus direct and indirect case supervision and caregiver training.
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 category of care 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 autism-related treatment, 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