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Acute Psych denials: what the review data shows
Independent reviewers have decided 39 published cases where an insurer denied Acute Psych — and they overturned the insurer 76.9% of the time. A denial for Acute Psych is a starting position, not a final answer.
Published decisions
39
2001–2026
Overturned
76.9%
30 denials reversed
Conditions behind acute psych denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Depression | 10 | 70% |
| Schizophrenia | 6 | 100% |
| Bipolar Disorder | 6 | 100% |
| Substance Use Disorder | 3 | 66.7% |
| High Risk Suicide | 3 | 66.7% |
Typical time to a decision
20 days
Most land between 15 and 21 days
Handled as urgent
28.2%
Expedited when a delay would cause harm
Recent direction
Rising
75% → 81.8% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for (1) inpatient hospitalization and (2) electroconvulsive therapy services (12 treatments).With regard to risk of harm, the records support a score of 5. The patient has an extreme risk of harm, due to a history of suicidal ideation, self-harm, and aggression towards others. During her hospitalization, she has been unable to go more than three days without the use of four-point restraints and no more than one day without self-harm or aggression towards others. In terms of functional status, the records support a score of 5. The documentation noted severe functional impairment as the patient struggles to complete her activities of daily living, including attending to her hygiene.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for inpatient (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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. Applying the CALOCUS framework, this patient meets the criteria for inpatient psychiatric level of care services.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for psychiatric inpatient hospitalization services provided at Westpark Springs from 11/01/22 through 11/21/22.The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.
Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for acute psychiatric inpatient treatment level of care services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
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 Psychwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.