Depression denials at external review

• rising

  It has risen over the published record: 56.7% in 2012 against 82.7% 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 — 320 decisions, which came out at 81.2%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

• concentrated

  82% of these disputes involved mental health alone (n=403, 79.2% overturned), so the headline figure for depression is largely that pairing.

• high volume

  With 492 decisions in 2021-2025, this is among the five most-disputed conditiones in the published record — one of the few where the numbers are stable enough to read year by year.

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 family81.2%320
• American Academy of Child and Adolescent Psychiatry75.7%136
• FDA67.6%34
• American Society of Addiction Medicine64.5%31
• American Psychiatric Association—9
• American College of Obstetricians and Gynecologists—1
• American College of Rheumatology—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.

• Mental Health79.2%403
• Pharmacy58.7%46
• Electro, thermal & radiofrequency—17
• Diagnostic imaging & screening—9
• Outpatient rehabilitation—4
• Acute inpatient medical—3
• Neurosurgery—3
• Autism-related treatment—2

Browse all treatment classes · Pick your own pair

• RTC77.0%252
• Intensive Outpt Prog90.2%41
• TMS80.5%41
• Partial Hospital82.1%39
• Anti-Depressants55.9%34
• Other—18
• Individ Counsel—15
• Psychotherapy—9

• Medical Necessity77.2%464
• Experimental/Investigational—27
• Urgent Care—1

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.