Acute Inpatient Hospitalization denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 54-year-old female with a long-standing history of diet pill dependence as well as what has been identified as an eating disorder due to long-standing binging on high-caloric foods such as pasta, pizza, and ice cream, though devoid of purging of any sort. By the point of her most recent inpatient admission, she was using up to 35 diet pills per day. Her past history was also notable for periods of depression and frank paranoia, the latter having been attributed to her use of the diet pills, including her feeling that she could read others’ thoughts and predict the future. She was admitted for inpatient treatment some seven weeks prior due to the psychotic symptoms but soon returned to use of the diet pills.

An enrollee has requested reimbursement and prospective authorization and coverage for continued acute inpatient hospitalization and residential treatment center services upon discharge from this acute inpatient stay. Findings: The physician reviewer found that the patient was hospitalized for a month. The patient was unable to sustain any therapeutic momentum from the admission. The patient had previously failed outpatient services, intensive outpatient programming and partial hospitalization. Regarding a specific episode of care, the patient was difficult to manage from the outset despite the highly-specialized setting of an acute inpatient psychiatric unit. Upon presentation, the patient was agitated, paranoid and manic. The records noted that the patient was hypomanic, paranoid, delusional, labile, agitated and suspicious.

Where the denial was upheld

A 35-year-old female enrollee has requested acute inpatient hospitalization for treatment of her schizoaffective disorder, personality diagnosis and migraine headaches. Findings: The physician reviewer found that the acute inpatient hospitalization services provided during the said time frame were not medically necessary. The patient’s psychiatric status was non-acute and symptoms of depression and anxiety were chronic and enduring. While these symptoms impacted the patient’s ability to function and needed to be addressed, they did not place her at acute and imminent risk. The patient did not require 24-hour supervised care by a physician as medication adjustments could have occurred safely in a less intensive setting such as a partial hospital program.

The patient is a 52-year-old male with a history of hypertension and asthma. He underwent spinal fusion surgery two weeks prior to hospital admission. He presented to the emergency room in October 2005 with shortness of breath and bilateral lower extremity swelling. His admission diagnosis was respiratory failure due to pneumonia/CHF. He was evaluated by pulmonology and started on intravenous antibiotics, intravenous steroids, oxygen, and regular nebulizer treatments. His chest x-ray demonstrated evidence of a density involving the posterior aspect of the right upper lobe and an infiltrate at the right base.

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 Acute Inpatient Hospitalization, then check the rights and deadlines that apply to your plan.