Condition class · category · California
Autism spectrum denials at external review
When a California health plan denied care for autism spectrum and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
59.4%
- Overturned
- 180 of 303
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Autism Spectrum
- Median days to decision
- 43
- All years
- 66.8% of 1,384
What stands out here
computed from this classrising
It has risen over the published record: 23.5% in 2007 against 65.3% in 2025. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.
most-cited standard
Reviewers named LOCUS family more than any other standard here — 38 decisions, which came out at 86.8%, 27 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
50% of these disputes involved autism-related treatment alone (n=151, 52.3% overturned), so the headline figure for autism spectrum is largely that pairing.
The trend, with its era
computedHover the chart for a year’s counts. Series stops at 2025 — report year 2026 uses a different category vocabulary.
What reviewers relied on
3 validated codesCalifornia 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.
| What the reviewer relied on | In overturns | In upholds |
|---|---|---|
| the FDA label or approval status | 2%n=180 | 0%n=123 |
| a standardised level-of-care instrument | 20%n=180 | 5%n=123 |
| a California statutory definition | 4%n=180 | 7%n=123 |
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.
Authorities named in this class
computed- LOCUS family86.8%38
- American Academy of Child and Adolescent Psychiatry76.7%30
- American Academy of Pediatrics—22
- American Psychiatric Association—3
- FDA—3
- American College of Rheumatology—2
- American Academy of Neurology—1
- American Society of Addiction Medicine—1
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.
By treatment
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Autism-related treatment52.3%151
- Durable medical equipment70.3%64
- Mental Health78.7%47
- Outpatient rehabilitation—15
- Diagnostic imaging & screening—13
- Pharmacy—4
- Home Health Care—3
- Acute inpatient medical—2
The specific treatments inside this class
below n=30, no rate is claimed- Appld Behav Analysis45.9%74
- Speech Therapy57.5%40
- Occupational Therapy45.2%31
- Other45.2%31
- Special Bed—26
- RTC—25
- Partial Hospital—9
- Speech Generate Device—9
By review type
computed- Medical Necessity59.2%292
- Experimental/Investigational—11
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.
Every figure on this page is conditional on a denial having reached external review. Fewer than 1% of denials are appealed internally at all, so this describes denials that were fought to the end — not denials in general — and it describes California only. Who this does not cover.
Free help, first: the California DMHC Help Center files your Independent Medical Review at no cost — 1-888-466-2219, dmhc.ca.gov.