What must denial appeals include?

• A. Evidence of medical necessity, functional deficits, justification for intervention, objective data, and citations of payer policy.
• B. Personal opinions about the patient.
• C. A summary of the therapy sessions.
• D. A request for faster approval.

Answer: (A)

In denial appeals, you need to demonstrate that OT is medically necessary and that the services are justified under payer guidelines, using concrete, objective data. The strongest appeal includes five elements:

• Evidence of medical necessity: clearly link the therapy to the child’s diagnosed condition and the need for OT to improve function and participation.

• Functional deficits: describe how impairments limit daily activities, school participation, play, self-care, or social interaction.

• Justification for intervention: explain why OT is the appropriate modality to address these deficits and what specific outcomes are expected with continued therapy.

• Objective data: provide measurable information such as standardized assessments, progress notes, goal attainment, and any change in function over time to show need and potential for improvement.

• Citations of payer policy: reference the specific coverage criteria, guidelines, or policy statements that support funding OT for this child, including relevant codes or authorization requirements when applicable.

Personal opinions about the patient, a mere summary of sessions, or a request for faster approval do not establish the necessary objective, policy-based justification. The appeal is strongest when it ties medical necessity to functional impact with solid data and payer policy support.