ADHD denials at external review

• most-cited standard

  Reviewers named LOCUS family more than any other standard here — 38 decisions, which came out at 78.9%, 16 points above the class as a whole. Citing a standard and the outcome share a cause; this is not the effect of naming it.

• concentrated

  47% of these disputes involved mental health alone (n=50, 72.0% overturned), so the headline figure for adhd is largely that pairing.

California requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.

Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.

• LOCUS family78.9%38
• American Academy of Child and Adolescent Psychiatry—14
• FDA—13
• American Society of Addiction Medicine—4
• American Academy of Pediatrics—2

A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.

• Mental Health72.0%50
• Pharmacy60.5%43
• Diagnostic imaging & screening—8
• Autism-related treatment—3
• Outpatient rehabilitation—2
• Diagnostic & physician evaluation—1

Browse all treatment classes · Pick your own pair

• ADD/ADHD Rx65.0%40
• RTC66.7%30
• Intensive Outpt Prog—6
• Other—5
• Psychological Evaluation—5
• Individ Counsel—4
• Partial Hospital—3
• Acute Psych—2

• Medical Necessity63.5%104
• Experimental/Investigational—3

Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.