Major Depressive Disorder With Psychotic Features: when insurers say no, reviewers often say yes

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. 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, with regard to risk of harm, the records support a score of 4.

The patient’s parent has requested authorization and coverage for six (6) months of RTC services to treat the patient’s major depressive disorder with psychotic features, substance abuse, and autism spectrum disorder. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm, due to repeated suicidality, substance use, anger and threats at home, and aggression during his most recent RTC admission. In terms of functional status, the records support a score of 4.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that that in order to objectively determine the appropriate level of care for this patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The patient had a suicide attempt several months ago with an attempt to overdose on Advil. However, around the first date of service in dispute, the patient did not have any suicidal ideation, homicidal ideation, psychosis, or hallucinations.

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting reimbursement for residential treatment center services. The enrollee was admitted for residential treatment services due to unstable mood, fluctuating energy level, acting out, and inability to attend school. Her treatment plan included individual psychotherapy two times per week, family psychotherapy once per week, group psychotherapy and psycho-education two to three times per day, nutrition consultation one to two times per week, physician consultation one to two times per week and psychiatric consultation once per week. Intake documentation describes the enrollee as disheveled, alert and oriented; with an anxious mood, cooperative behavior, and poor insight. The enrollee reported a history of visual and auditory hallucinations and reported she was experiencing these during the intake interview.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for major depressive disorder with psychotic features was denied, the published record says the denial is worth fighting.