Suicidality: when insurers say no, reviewers often say yes
In 15 published external-review decisions involving suicidality, independent physician reviewers overturned the insurer’s denial 93.3% of the time.
Most-fought treatments for suicidality
| Category | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 5 | 100% |
| Inpatient Psychiatric Hospitalization | 3 | 66.7% |
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for psychiatric residential treatment center (RTC) services. 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. The composite score is then used to determine the level of care needed.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services.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 children needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 4, which corresponds with serious risk of harm. This is due to the patient’s recent suicidality, impulsivity, and struggles with basic self-care and hygiene prior to admission and during the first two weeks of his RTC treatment.
Where the denial was upheld
A 19-year-old female has requested past and prospective coverage for inpatient psychiatric treatment of her behavioral health issues. Findings: The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness. This patient presented as a distressed, mentally ill patient. The patient’s records throughout the hospitalization demonstrate the patient could have been safely and effectively treated in a less restrictive setting as of the date in question. The American Psychiatric Association (APA) recommends the “psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patient’s safety, but also to promote improvement in the patient’s condition.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 suicidality was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY