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Individ Counsel denials: what the review data shows
Independent reviewers have decided 130 published cases where an insurer denied Individ Counsel — and they overturned the insurer 66.9% of the time. A denial for Individ Counsel is a starting position, not a final answer.
Published decisions
130
2001–2026
Overturned
66.9%
87 denials reversed
Conditions behind individ counsel denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Depression | 42 | 78.6% |
| Anxiety | 26 | 69.2% |
| Bipolar Disorder | 14 | 92.9% |
| Depression - Severe | 9 | 44.4% |
| ADHD | 8 | 75% |
| PTSD | 6 | 66.7% |
| Eating Disorder | 3 | 66.7% |
| Substance Abuse | 3 | 0% |
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. | 126 | 69% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 4 | 0% |
Typical time to a decision
12 days
Most land between 5 and 21 days
Handled as urgent
39.2%
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 has requested authorization and coverage for weekly therapy that includes eye movement desensitization and reprocessing (EMDR), dialectical behavior therapy (DBT), and cognitive behavioral therapy (CBT). The 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.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for family therapy once per week and/or individual therapy services twice per week, or in the alternative, individual therapy services once 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.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization for residential treatment center (RTC) services (ASAM 3.5) that include treatment for compulsive sexual behaviors with a multidisciplinary team which includes certified sex addition therapists (CSAT). For Dimension 1, In this case, the patient will be going into RTC treatment following prior detoxification. The patient is experiencing or anticipated to imminently experience mild to moderate signs and/or symptoms of intoxication that can be addressed in any level of care as needed and thus does not require a medically managed addiction treatment program for intoxication management.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, eye movement desensitization and reprocessing (EMDR) 1x/week, and family therapy 1x/week. Findings: The physician reviewer found that At issue in this case is whether the daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, EMDR 1x/week, and family therapy 1x/week are medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below.
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 Individ Counselwhen 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.