Sev Emot Disturb: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient is a 17-year-old male referred for residential treatment due to increasingly aggressive behavior at school. Other behaviors included extensive use of marijuana and alcohol beginning at age 11, threatening to make bombs, threatening to shoot people, thievery, and sexual deviance. The latter consisted of bestiality, manipulation of peers to engage in sexual acts and sexual intimidation towards his sister. There is a 2001 report, which cites direct sexual abuse by his older brother on at least four to five occasions, as well as the observation of the brother forcing his sister to engage in sexual acts.

The parent of an 18-year-old male enrollee has requested residential treatment center services for treatment of the enrollee’s serious emotional disturbance. Findings: The physician reviewer found that this patient with a history of multiple behavioral problems including: major depressive disorder, recurrent, severe, in partial remission, polysubstance dependence including hallucinogens, cannabis and opiates, conduct disorder, parent-child relational problems, tic disorder not otherwise specified (NOS), anxiety disorder NOS and personality disorder NOS including narcissistic, antisocial and schizotypal was placed in the residential treatment facility for control of his behaviors which had previously been difficult to manage.

Where the denial was upheld

The parent of a 15-year-old male has requested coverage for past residential treatment level of care services for treatment of his behavioral health issues. Findings: The physician reviewer found that due to multiple factors and unique considerations, determination of the appropriate level of care for patients with inattention, impulsivity, disobedience, and mood symptoms coupled with strained family dynamics and budding characteristics is a challenging endeavor. Clinical guidelines and patient placement criteria have been developed to assist care providers with the complex determination process. Regarding this patient’s case, the documentation provided fails to demonstrate that the patient could not consolidate meaningful treatment gains in a less restrictive level of care.

The patient is a 14-year-old female with a recent history of risky behavior. She has been exhibiting acting out behaviors since the age of 10. She has a history of running away from home and drug and alcohol abuse. Recently, the patient was placed on a 5150 psychiatric hold after she assaulted a family friend who attempted to prevent her from running away. On 7/16/04, the patient was admitted to a residential psychiatric treatment facility. The submitted treatment notes indicate the patient is not suicidal. On 8/10/04, the patient’s psychiatrist noted there was no need for psychotropic medication. A request has been made for continued residential psychiatric treatment services.

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 sev emot disturb was denied, the published record says the denial is worth fighting.