Acute Psych Admit denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient hospitalization services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s behavioral health conditions. This patient was admitted to the inpatient unit due to possible suicidal ideation and issues with relationships and inappropriate behaviors on the internet. On an initial evaluation, the patient reported some possible passive suicidal ideation. This passive suicidal ideation appeared to abate after her first day in the hospital. She did not have any active suicidal ideation or plans to harm herself and did not make any attempts to harm herself or others during her hospital stay.

An enrollee who was admitted to the inpatient facility, with auditory hallucinations. He denied any suicidal ideation, self-harm, or substance use. Review of his medical records noted that the patient had slept well. His thought process was tangential and he denied any suicidal or homicidal ideation. His medications were not changed on this date, and his valproic acid level was therapeutic. The patient displayed some grandiose thoughts, and was euthymic. He reported some continued auditory hallucinations that were not bothersome, and he denied suicidal and homicidal ideation. He was started on lithium on this date. The patient substantially participated in individual therapy, and showed progress and cooperative behavior in all group activities. The patient did not demonstrate understanding of the reasons for his hospitalization. The patient presented with grandiose thoughts.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the acute inpatient psychiatric level of care services received. between two separate ranges of dates of service. Findings: The physician reviewer found that the patient was admitted to the inpatient unit due to anxiety issues and behavioral problems. It is noted that prior to each of the disputed inpatient stays, the patient had been treated in an acute inpatient psychiatric level of care. The records demonstrate that when the patient was eventually admitted to the inpatient stays, he was not experiencing acute psychiatric symptoms. During the prior stay, the patient presented with recent homicidal ideation; however, this homicidal ideation was not present at the time of admission and did not reoccur at any time during the patient’s stay.

The patient is diagnosed with mood disorder, attention deficit/hyperactivity disorder, and provisional autism spectrum disorder. In 2016, the patient was hospitalized due to threatening harm to her mother. She had also run away twice. On 6/11/18, the patient was admitted to inpatient psychiatric hospitalization due to behavioral issues and threats of self-harm. On admission, the patient was noted to be restless with a tangential thought process and poor hygiene. She denied medical problems, substance abuse, and suicidal ideation. On 6/18/18, the patient was noted to be less irritable and less labile. On 6/24/18, the patient was noted to show cooperative behavior with normal mood, speech, and thought process. On 6/28/18, the patient refused to speak with a psychiatrist. On 7/3/18, the patient was diagnosed with provisional autism spectrum disorder.

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