Treatment class · subcategory · California
Occupational Therapy denials at external review
When a California health plan denied care in the occupational therapy class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
43.5%
- Overturned
- 20 of 46
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Occupational Therapy
- Median days to decision
- 35
- All years
- 64.1% of 276
Authorities named in this class
computed- American Academy of Pediatrics—10
- American Academy of Child and Adolescent Psychiatry—3
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 condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Autism spectrum45.2%31
- Mental health—4
- Cardiac & circulatory—3
- Orthopedic & musculoskeletal—3
- Pediatrics—3
- Cancer—1
- Immune disorders—1
The specific conditions inside this class
below n=30, no rate is claimed- Autistic Disorder45.2%31
- Other—3
- ADHD—2
- Develop Delay/ Cog—2
- Stroke/ CVA—2
- Bone Fracture/Break—1
- Brain—1
- Heart Attack—1
By review type
computed- Medical Necessity38.5%39
- Experimental/Investigational—7
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.