Acute Inpatient Psychiatric Admission denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for acute inpatient treatment pending residential treatment center placement.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.

The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient level of care provided. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that based on review of the available records, the acute inpatient services were medically necessary from the dates at issue. This patient already had two prior inpatient psychiatric admissions within the previous six months of this admission. The provider’s notes indicate the patient’s diagnosis was questioned and his previous treatment with Risperdal, Depakote and lithium was changed.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement for acute inpatient psychiatric services. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Applying the child and adolescent level of care utilization system criteria to determine the appropriate level of care, the patient demonstrated some risk of harm (score 2) due to his history of aggression. The patient’s functional status was moderately compromised (score 3) given his issues with role performance due to psychiatric symptoms. The patient did not have any medical, addictive, or psychiatric co-morbidity (score 1). His recovery environment was mildly stressful (score 2) and he was noted to have a stable living environment.

A 32-year-old female enrollee has requested acute inpatient psychiatric treatment at Palomar Medical Center for the treatment of her behavioral health problems. Findings: The physician reviewer found that the submitted clinical evidence demonstrates this patient’s admission was prompted by deterioration in poor self-care due to non-adherence to her psychiatric treatment (with resultant psychosis). This exacerbation of her paranoia and hallucinations resulted in her not eating or caring for herself and her unborn fetus – and led to her being detained into an inpatient setting for both her safety and the well being of her unborn fetus. While she showed ongoing limited insight into her psychiatric symptoms, the submitted documentation indicates that the patient responded to treatment and was compliant with treatment (including medications and frequent fetal monitoring).

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Acute Inpatient Psychiatric Admissionwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.