Acute Psych Dischg denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 16-year-old female who had been in treatment with mental health provider’s within the Health Plan prior to her admission to the non-Plan acute inpatient psychiatric facility for comprehensive evaluation. The evaluation was prompted by the patient stealing money from her aunt and also having a disassociative/transient psychotic episode. The patient also had recently disclosed that she was sexually molested when on visitation with her father by a perpetrator with whom she was left alone. The patient lives with her biological mother and step-father. There continues to be some interaction and visitation with the biological father.

A female enrollee has requested reimbursement for the Residential Treatment Center (RTC) Services.The patient has a history of two previous treatments for the diagnoses of alcohol use disorder, with resulting relapse. The patient demonstrated significant cravings, depression, anxiety, and flashbacks. She did not recognize relapse triggers and demonstrated a lack of insight into the benefits of care. The patient made progress in addressing her alcohol use disorder, post-traumatic stress disorder (PTSD), and major depression. She was able to cope with emotions during telephone contact with her mother. The documentation showed a lack of evidence for the need for ongoing care at this level of RTC with a decrease in cravings, depression, anxiety, and flashbacks; and participation in recovery, and discharge planning.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient psychiatric hospitalization from 2/16/16 through 3/10/16. 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. It does not appear that the patient needed inpatient psychiatric management. The patient did not exhibit dangerous behaviors towards herself or others and was fully cooperative during treatment. It appears that she could have received mental health treatment in a less restrictive setting than an inpatient psychiatric setting due to her overall stable symptoms. She was not noted to have any severe mood swings or manic symptoms associated with her mood disorder.

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