Treatment class · subcategory · California
RTC denials at external review
When a California health plan denied care in the rtc class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
79.4%
- Overturned
- 916 of 1,153
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- RTC
- Median days to decision
- 21
- All years
- 80.6% of 1,384
What stands out here
computed from this classmost-cited standard
Reviewers named American Society of Addiction Medicine more than any other standard here — 567 decisions, which came out at 79.0%. Citing a standard and the outcome share a cause; this is not the effect of naming it.
high volume
With 1,153 decisions in 2021-2025, this is among the five most-disputed treatment classes in the published record — one of the few where the numbers are stable enough to read year by year.
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 | 0%n=916 | 0%n=237 |
| a standardised level-of-care instrument | 98%n=916 | 96%n=237 |
| a California statutory definition | 3%n=916 | 6%n=237 |
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- American Society of Addiction Medicine79.0%567
- LOCUS family80.1%533
- American Academy of Child and Adolescent Psychiatry75.1%189
- American Psychiatric Association—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 condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Mental health79.1%1,122
- Autism spectrum—25
- CNS & neuromuscular—2
- Cardiac & circulatory—1
- Endocrine & metabolic—1
- Infectious disease—1
- Pediatrics—1
The specific conditions inside this class
below n=30, no rate is claimed- Substance Use Disorder82.6%351
- Depression77.0%252
- Alcohol Use Disorder80.2%177
- Anxiety67.0%100
- Bipolar Disorder79.7%59
- PTSD90.3%31
- ADHD66.7%30
- Eating Disorder83.3%30
By review type
computed- Medical Necessity79.5%1,151
- Experimental/Investigational—2
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.