Your insurance rights, in plain English

The short version

If your plan covers pediatric therapy at all, California's mental health and habilitative-services rules require it to cover medically necessary speech, OT, and PT for children, and to treat it the same way it treats any other medical specialty. 'Medical necessity' is determined by your treating clinician's documentation, not by the insurance company's preference for group over individual sessions.

The part most families don't know: you can request the clinical criteria your plan uses, in writing, and they must provide it. Vague denials become much harder to write once the criteria are on record.

The phrase that un-sticks claims

When a denial says 'not medically necessary,' the most effective appeal letter we've seen is one paragraph: a short description of the functional limitation in the child's own daily life, the clinician's recommendation, and the sentence 'Please provide the written medical-necessity criteria used for this determination.'

It works because it forces the plan to either specify a criterion the care clearly meets or escalate the review. About half of first-level denials in our experience reverse at this stage.

When to call for help

If a second-level appeal fails, the California Department of Managed Health Care runs a free Help Center that resolves plan disputes, and it has actual enforcement power. Every family we've sent there came back with an answer, usually within a month.

Our office will draft the appeal letter with you, free, whether or not your child is our patient. Ask for Wren.