PTSD denials in California external review
In the California DMHC record, independent physician reviewers decided 103 published external-review cases involving PTSDand overturned the plan’s denial in 71.8%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for PTSD
| Category | Decisions | Overturned |
|---|---|---|
| RTC | 39 | 89.7% |
| Intensive Outpt Prog | 10 | 80% |
| Partial Hospital | 10 | 80% |
| Psychotherapy | 7 | 57.1% |
| RTC Admit | 7 | 42.9% |
| Individ Counsel | 6 | 66.7% |
| SCP Consult Refer | 3 | 33.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization & coverage for 6 months of residential treatment center (RTC) upon discharge from the acute inpatient level of care (LOC). The American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists 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 CALOCUS-CASII. This instrument provides a reliable framework for determining the appropriate LOC 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.
Findings: The physician reviewer found that The parent of an enrollee has requested reimbursement and authorization and coverage for Intensive Outpatient Program (IOP) services.At issue in this case is whether the requested Intensive Outpatient Program (IOP) services 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. “Medically necessary treatment of a mental health or substance use disorder” is defined in Health and Safety Code section 1374.72(a)(3)(A) as follows:(A) For purposes of this section, “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 progress…
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Inpatient Behavioral Health services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the clinically appropriate level of care for a child or adolescent in 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) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others.
Nature of Statutory Criteria/Case Summary: The parents of an enrollee has requested reimbursement and prospective authorization and coverage for any or all requested partial hospitalization program (PHP) services from 9/01/21 forward.At issue is whether any or all requested PHP services from 9/01/21 forward were and are medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below.
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 PTSD, 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