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Behavioral Therapy denials: what the review data shows
Independent reviewers have decided 78 published cases where an insurer denied Behavioral Therapy — and they overturned the insurer 51.3% of the time. A denial for Behavioral Therapy is a starting position, not a final answer.
Published decisions
78
2001–2026
Overturned
51.3%
40 denials reversed
Conditions behind behavioral therapy denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Depression | 7 | 42.9% |
| ADHD | 7 | 42.9% |
| Anxiety | 6 | 83.3% |
| Depression - Severe | 5 | 20% |
| Bipolar Disorder | 4 | 75% |
| Autistic Disorder | 3 | 33.3% |
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. | 70 | 52.9% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 7 | 42.9% |
Typical time to a decision
19 days
Most land between 8 and 21 days
Handled as urgent
26.9%
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
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for weekly intensive behavioral therapy 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.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for weekly intensive behavioral therapy services. Findings: The physician reviewer found that 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.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Inpatient Behavioral Health services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. Using CALOCUS, 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) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient behavioral health services for treatment of the enrollee’s behavioral health condition.Findings: The physician reviewer found that submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. In cases such as this, an evidence based, objective, instrument such as the Level of Care Utilization System (LOCUS) is an accepted, national standard for determining the appropriate level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. The patient met the following criteria: According to the records, it does not appear that the patient has a history of suicide attempts.
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 treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Behavioral Therapywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
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.