Acute Inpatient Psychiatric denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for acute inpatient psychiatric services at Stanford Medical Center. 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. With regard to risk of harm, the records support a score of 5.

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute inpatient psychiatric services provided for treatment of his behavioral health condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient appears to have a medical disorder in context of a serious formal thought disorder, which as a class represents the most severe of psychiatric illnesses. He has multiple risk factors, and his particular condition is consistent with the conceptualization of grave disability. Prematurely discharging a patient under such circumstance would be inconsistent with contemporary practice standards, thus a conservative hospitalization was to be expected. Although formidable chronicity had declared itself, the patient was still gravely disabled.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization, and coverage for acute inpatient psychiatric services. Most evidence-based treatment guidelines concur that the deciding factor on whether inpatient psychiatric care is necessary is whether patients appear to be a harm to themselves or others. Milliman guidelines agree on this point and additionally cite factors such as overt psychotic ideation, complex biomedical issues, grave disability impairing daily living function, and/or high levels of impulsivity, aggression or mania. In this case, the patient was not evincing suicidal or homicidal ideation. He was not expressing overt psychosis. There was no issue of self-injurious behavior or complex medical issues.

A 39-year-old female enrollee requested continued acute inpatient psychiatric services provided for medical treatment of her behavioral health conditions. Findings: The physician reviewer found that considering the patient’s diagnoses, history and symptom burden upon presentation, treatment at the acute level of care was initially indicated. However, the medical records do not support the medical necessity for continued inpatient care as the patient was complying with rules and structure. Despite her anxiety and pain, she was not demonstrating any unsafe behavior. The patient was independent in her activities of daily living. The patient’s antidepressant medication was increased. She had been stable on her other medicines, which included a second generation antipsychotic. Subsequently, the patient had a brighter disposition with decreased paranoia and thought blocking.

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 Psychiatric, then check the rights and deadlines that apply to your plan.