Panic Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for partial hospitalization program (PHP) level of care services. Findings: The physician reviewer found that American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (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 is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria this patient met Level 3.5 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 a slow taper of clonazepam and she experienced substantial difficulty and complaints of anxiety, panic, insomnia, poor concentration, and irritability.

Where the denial was upheld

Physician 1: The patient is a 27-year-old female who states that she has had problems with anxiety and panic episodes since adolescence. She has presented herself to the Emergency Department on two occasions for panic attacks manifested by dizziness, palpitations and difficulty concentrating. The patient has had trials of Celexa and Xanax but no information is available concerning the effect of these medications on her anxiety and panic episodes. She was referred by her primary care provider for a consultation with an integrative medicine specialist in May 2006. The specialist recommended a treatment plan including yoga, hypnosis and biofeedback and made a referral to a psychotherapist as well. It is not known from the record if the patient pursued psychotherapy.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for inpatient psychiatric services. The enrollee has a history of major depression, severe; with anxiety, panic disorder, and agoraphobia. She entered the inpatient psychiatric setting. Upon admission, she was tearful, anxious, perseverative, and hyper-focused on medications. She reported a decrease in eating and sleeping. She reported feeling isolated and withdrawn and she did not feel safe from hurting herself. She had severe anxiety and could not leave the apartment for fear she may die if she left. During her hospital stay, she was functional in the open unit after being treated in the locked unit. The provider notes at discharge state there is no clinical indication for her to remain in the facility. He notes she is not suicidal; she is agoraphobic.

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