Traumatic Brain Injury denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for full day speech, physical, and occupational therapies performed for up to four hours per day, five days per week. Current medical literature supports the use of rehabilitation in the context of traumatic brain injury (TBI). Researchers conclude regarding the effects of physical therapy interventions on balance impairments in individuals with TBI, “The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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) medical, addictive 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.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methicillin-resistant staphylococcus aureus (MRSA) assessment, neurology assessment, magnetic resonance imaging (MRI) scan, Ross Information Processing Assessment, Second Edition (RIPA-2) testing, and daily physical therapy. Findings: The physician reviewer found that with regards to the request for MRSA assessment, active surveillance consists of performing screening cultures (of the nares, oropharynx, and/or perineum) to identify asymptomatic patients who are colonized with antibiotic-resistant bacteria. This is typically performed in a hospital with the goal of prevention of spread of MRSA to other patients. Active surveillance cultures appear to be most useful in the setting of hospital outbreaks and among patients at high risk for MRSA carriage.

Physician 1The patient is a 56-year-old male who experienced a head injury in July 2003. He showed mild cognitive deficits upon neuropsychological testing. The submitted records indicate the patient received speech therapy. He currently has a mild cognitive deficit. The patient consulted a neuropsychologist who recommended cognitive rehabilitation therapy. The Health Plan has denied authorization for cognitive rehabilitation therapy on the basis that it is considered investigational.Upon review of the submitted records it appears the patient’s cognitive issues are mild. Cognitive rehabilitation therapy was not ordered by the patient’s physician who has been directing the patient’s neurologic care. Cognitive rehabilitation in this setting is unlikely to be more effective than continued standard therapy.

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 traumatic brain injury, then check the rights and deadlines that apply to your plan.