Acute Inpatient Psychiatric Treatment denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment for treatment of the enrollee’s delusions and hallucinations. Findings: The physician reviewer found that based on the available documentation, the services could not have reasonably been delivered effectively at a less restrictive setting. The patient had a serious underlying formal thought disorder as evidenced by her hospitalization two months prior and complicated by her substance use, non-adherence with medications, and lack of family support. The patient was guarded, suspicious and delusional. The patient was deemed to be gravely disabled due to an inability to provide self-care secondary to her psychosis.

A 41-year-old female enrollee has requested coverage for acute inpatient psychiatric treatment for treatment of her bipolar disorder and bulimia. Findings: The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains; however, placement in more restrictive settings is often clinically appropriate. In this particular case, acute hospitalization was indicated. Discharge on the date in question would have more than likely burdened the patient with undue morbidity and an elevated risk for readmission. On that date the patient was described as hopeless and suicidal per nursing, while the physician reported “near constant suicidal thoughts” and the patient’s fear that she might act on them.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the records were analyzed based on the Level of Care Utilization System (LOCUS) criteria. This is an accepted, national standard for determining the appropriate level of care for adults. In terms of risk of harm, the records support a score of 4. The patient has a history of suicide attempt. She has chronic suicidal ideation and can be impulsive. It was noted that the patient’s suicidal ideation had improved, although her suicidal thoughts remained present. With regards to functional status, the records support a score of 4.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient psychiatric treatment for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to support the medical necessity of the services at issue. The patient had a somewhat difficult course after his initial admission. Despite his changing polypharmacy regimen, he remained actively psychotic, with intrusive and sometimes aggressive behavior. He lacked either the ability or the desire to attend to hygiene and grooming. He then developed transaminitis, his medications were held, and he cleared up. His medications were changed, and he started Invega Sustenna. He began to show improvement in hygiene, behavior, and psychotic symptoms.

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