Brain Injury Concussion denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for full day speech, physical, and occupational therapies performed for up to four hours per day, five days per week. Current medical literature supports the use of rehabilitation in the context of traumatic brain injury (TBI). Researchers conclude regarding the effects of physical therapy interventions on balance impairments in individuals with TBI, “The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged dimensional rating system. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (A–Stressors, and B-Supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan. Researchers define traumatic brain injury (TBI) as an alteration in brain function, or other evidence of brain pathology, caused by an external force. TBI encompasses a broad range of pathologic injuries to the brain, of varying clinical severity, that result from head trauma. Researchers note that in patients with mild TBI, head computed tomography (CT) without contrast is the most appropriate examination choice. Head magnetic resonance imaging (MRI) without contrast may be sensitive in detecting intracranial injury that is occult on CT, such as subtle blood products or secondary signs of injury like edema.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient acute rehabilitative care that includes one-on-one pool therapy.Functional impairments due to traumatically acquired brain insults can improve with time, i.e., natural recovery processes. Researchers state that these impairments are also generally amenable to rehabilitation interventions. According to medical literature, the standard of care for rehabilitation in the setting of acute traumatic brain injury includes efforts to foster neurological recovery, mitigate risk of complications, improve function, advise on appropriate durable medical equipment, train family members/caregivers, and aid in the transition back to the community when feasible.

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 brain injury concussion, then check the rights and deadlines that apply to your plan.