Psychosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested reimbursement for residential treatment center (RTC) services. The 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. 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 and authorization and coverage for Residential Treatment Center (RTC) services (equivalent to ASAM 3.1).At issue in this case is whether the requested Residential Treatment Center (RTC) services (equivalent to ASAM 3.1) were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the patient’s mental health or substance use disorder.California Health and Safety Code section 1374.72(a)(3)(A) states that “Medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is al…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient psychiatric treatment for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to support the medical necessity of the services at issue. The patient had a somewhat difficult course after his initial admission. Despite his changing polypharmacy regimen, he remained actively psychotic, with intrusive and sometimes aggressive behavior. He lacked either the ability or the desire to attend to hygiene and grooming. He then developed transaminitis, his medications were held, and he cleared up. His medications were changed, and he started Invega Sustenna. He began to show improvement in hygiene, behavior, and psychotic symptoms.

Nature of Statutory Criteria/ Case Summary: The enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services. Findings: The physician reviewer found that the enrollee has a history of depression, psychosis, substance use, including cannabis and prescription amphetamines. He was actively abusing marijuana and prescription amphetamines. He transitioned from PHP to an intensive outpatient program (IOP). Notes indicated no current suicidal ideation. He denied a history of ever acting on suicidal ideation. Psychiatry notes indicated improvement in mood, good energy, feels rested, normal speech, no suicidal/homicidal ideation, no auditory verbal hallucinations, started gaining insight into connection between substance use, psychosis and social isolation.

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