Bipolar Ii Disorder denials in California external review
In the California DMHC record, independent physician reviewers decided 16 published external-review cases involving bipolar ii disorderand overturned the plan’s denial in 37.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for bipolar ii disorder
| Category | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 4 | 75% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 13 | 38.5% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 33.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meet Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient underwent detoxification and has not demonstrated any symptoms of withdrawal while in residential care.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) (ASAM 3.5) services. Per researchers’ criteria, this patient met Level 3.5 criteria for RTC services. Researchers’ criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient does not have symptoms of withdrawal following detoxification. The patient’s withdrawal needs were safely managed in a Level 3.5 setting.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient is a female with diagnoses of severe opioid use disorder, other severe stimulant dependence, bipolar II disorder, and generalized anxiety disorder. A review of the record indicates that the patient had prior treatment that included detoxification and residential treatment center (RTC) level of care treatment in 2012, 2014, and 2016. She reported relapse after these admissions. The patient was admitted on for detoxification with a plan to discharge her to the RTC program. She was medically cleared from detoxification. Physician progress notes indicate that the patient was calm and cooperative with clear and coherent speech. Her mood and her affect were euthymic. Her thoughts were goal oriented. She denied current suicidal and homicidal ideation. She reported previous thoughts of suicide with a plan to overdose in 2015.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the intensive outpatient program services provided from the end of October of 2018, going forward. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s intermittent explosive disorder and bipolar II disorder.At issue in this case is whether the intensive outpatient program services provided from the end of October of 2018, going forward are medically necessary for treatment of the enrollee’s behavioral health condition.In cases such as this, an evidence based instrument such as the CALOCUS (Child and Adolescent Level of Care Utilization System) is indispensable for determining necessary level of care for children, to insure their level of care meets their individual needs at the least restri…
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving bipolar ii disorder, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY