Mood Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for residential treatment center (RTC) services (ASAM 3.1) level of care services.Findings: The physician reviewer found that Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services for the time period under review. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and associated risk, withdrawal and associated risks, and addiction medication needs; (2) biomedical conditions including physical health concerns and pregnancy-related concerns; (3) psychiatric and cognitive conditions and history including active psychiatric symptoms and persistent disability; (4) substance use-related risks including the likelihood of engaging in risky substance use and the likelihood of engaging in ri…

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings: The physician reviewer found that The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for family therapy every 2-3 weeks.The Researchers provide 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.

The patient is diagnosed with mood disorder, attention deficit/hyperactivity disorder, and provisional autism spectrum disorder. In 2016, the patient was hospitalized due to threatening harm to her mother. She had also run away twice. On 6/11/18, the patient was admitted to inpatient psychiatric hospitalization due to behavioral issues and threats of self-harm. On admission, the patient was noted to be restless with a tangential thought process and poor hygiene. She denied medical problems, substance abuse, and suicidal ideation. On 6/18/18, the patient was noted to be less irritable and less labile. On 6/24/18, the patient was noted to show cooperative behavior with normal mood, speech, and thought process. On 6/28/18, the patient refused to speak with a psychiatrist. On 7/3/18, the patient was diagnosed with provisional autism spectrum disorder.

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 mood disorder, then check the rights and deadlines that apply to your plan.