50% overturnedAppeal outcomes · Therapy

Denied occupational therapy: what independent reviewers actually decided

Occupational therapy split evenly on appeal — and fared more than twice as well as physical therapy, on much the same kind of denial.

Occupational therapy evaluation and treatment aimed at activities of daily living and functional participation, billed by the treating clinician and reviewed against visit limits and progress criteria.

What the independent reviewers decided

50%

overturned by the independent reviewer

34

of 68 decisions in the corpus

Source

California DMHC independent medical review determinations, 2017-2026. Public record.

Read this as a base rate, not as your odds

These are decisions about other patients, in one state, that had already been through the plan's own internal appeal and were then sent to an outside reviewer. That population is self-selected toward disputes worth pursuing, so the rate says what happened to cases like this at that stage — not what will happen to a specific claim. It is not medical or legal advice.

Why plans deny occupational therapy

  • The visit allowance for the benefit year has been reached.
  • Progress is read as a plateau under the policy's continuation criteria.
  • The goals are characterised as vocational, educational or custodial rather than medical.
  • The plan of care does not tie each intervention to a documented deficit.

What actually carried the cases that won

Functional impact carried 65% of the reversals, with guideline support at 50%. That the reversal rate is more than double physical therapy's, on similar denial grounds, is the most useful thing in this profile: occupational therapy records tend to describe activities of daily living natively, and that is the language these decisions were decided in. The reversals named the task the patient could not perform and the deficit behind it. Peer-reviewed literature was the authority cited most.

What the record showedShare of overturned decisions
The functional impact on the patient was documented65%
A published guideline supported the request50%
The condition was documented as chronic or long-standing24%
The diagnosis was confirmed21%
The severity or urgency was documented21%
Prior treatment was documented12%
Conservative treatment was documented as failed9%

Shares are of the overturned decisions and do not sum to 100% — a single decision often rested on more than one, and some rested on none of these.

What the reviewers cited

  • Peer-reviewed literature — in 41% of the overturned decisions
  • Clinical guidelines — in 12% of the overturned decisions
  • Specialty-society criteria — in 12% of the overturned decisions
  • Standard of care — in 9% of the overturned decisions

occupational therapy denials — frequently asked

Is denied occupational therapy worth appealing?
It divides exactly down the middle — 34 reversed and 34 upheld across 68 California determinations.
Why does it fare better than physical therapy?
In this corpus the difference is documentation, not policy. Occupational therapy notes describe activities of daily living as a matter of course, and functional impact was present in 65% of the reversals. Records that name the task and the deficit behind it gave the reviewer what these decisions turned on.
How is a vocational characterisation answered?
By anchoring the goal to a medical deficit. The reversals connected each intervention to an impairment documented in the record rather than to a workplace or classroom outcome.

Related guides

CO-50 — not medically necessaryBenefit maximum denialsMedical necessity appeal letters

Source

Denial reasons and criteria are described in plain language for reference and vary by plan and policy. This page reports what independent reviewers decided in a public California dataset; it is general information, not medical, legal, or coverage advice.

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