Major Depression denials in California external review
In the California DMHC record, independent physician reviewers decided 129 published external-review cases involving major depressionand overturned the plan’s denial in 51.9%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for major depression
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment | 18 | 44.4% |
| Residential Treatment Center | 18 | 77.8% |
| TMS | 17 | 52.9% |
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. | 106 | 54.7% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 21 | 38.1% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.5 criteria for the Residential Treatment Center services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient was treated with a benzodiazepine taper after his transfer from the hospital. He had post-acute withdrawal syndrome (PAWS) symptoms of diaphoresis, tremors and anxiety. The patient’s withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient fractured his clavicle when he fell due to a grand mal seizure.
Where the denial was upheld
Physician 1: The patient is a 31-year-old female who is requesting authorization for vagus nerve stimulation (VNS) treatment for major depression. The patient has not shown sustained improvement with conventional anti-depressants and electroconvulsive (ECT) therapy. The Health Plan has denied the patient’s request indicating VNS therapy is investigational and therefore not a covered benefit.To date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of established principles of health care practice as of this date for the management of refractory depression. VNS remains an experimental, controversial and unproven procedure at this time.
Physician 1: The patient is a 55-year-old female with a diagnosis of major depression. She is now seeking vagus nerve stimulation (VNS) therapy for treatment and management of her depression. Her provider reports the patient’s condition has been refractory to psychopharmacological treatment and electroconvulsive therapy (ECT). The Health Plan has denied authorization for VNS therapy on the basis that it is an experimental treatment and therefore a non-covered benefit. The patient is appealing the Health Plan’s denial.To date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of the established principles of health care practice as of this date for the management of refractory depression.
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 major depression, 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