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Partial Hospitalization Program denials: what the review data shows
Independent reviewers have decided 424 published cases where an insurer denied Partial Hospitalization Program — and they overturned the insurer 62.3% of the time. A denial for Partial Hospitalization Program is a starting position, not a final answer.
Published decisions
424
2001–2026
Overturned
62.3%
264 denials reversed
By condition
Published outcomes when Partial Hospitalization Program was denied for these conditions.
| Condition | Decisions | Overturned |
|---|---|---|
| Depression | 99 | 66.7% |
| Eating Disorder | 70 | 60% |
| Autism Spectrum Disorder | 31 | 61.3% |
| Anxiety | 30 | 70% |
| Suicidal Ideation | 28 | 75% |
| Post-traumatic Stress Disorder | 27 | 70.4% |
| Bulimia Nervosa | 26 | 65.4% |
| Alcohol Use Disorder | 25 | 68% |
| Anorexia Nervosa | 25 | 56% |
| Major Depressive Disorder | 25 | 56% |
| Substance Use Disorder | 24 | 50% |
| ADHD | 24 | 58.3% |
| Bipolar Disorder | 23 | 69.6% |
| Anxiety Disorder | 16 | 87.5% |
| Obsessive-compulsive Disorder | 15 | 80% |
Typical time to a decision
16 days
Most land between 5 and 21 days
Handled as urgent
37.3%
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 The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services (ASAM level 2.5) received from 2/27/23-3/20/23 and/or intensive outpatient program (IOP) services (ASAM level 2.1) received from 3/21/23-forward. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.5 criteria for PHP services received from 2/27/23-3/20/23.
Nature of Statutory Criteria/Case Summary: Patient has requested reimbursement for residential treatment center (RTC) services & partial hospitalization program (PHP) services. The AACAP & AACP have unified the CALOCUS & CASII into a single instrument, the CALOCUS-CASII. This instrument is a standardized tool used to determine the intensity of services needed for children & adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical &/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use & psychiatric conditions; (4) recovery environment (a. stressors & b. supports); (5) resiliency & response to services; & (6) engagement. The composite score is then used to determine LOC needed.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parents of a patient requested reimbursement for the partial hospitalization services provided. Two authorities on childcare 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 has requested reimbursement for partial hospitalization program (PHP) 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.
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 Partial Hospitalization Programwhen 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.