Admission denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for mental health inpatient level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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) medical, addictive 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. For dimension 1, with regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for the full inpatient hospital stay. Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given when signs and symptoms include viral upper respiratory prodrome followed by increased respiratory effort, wheezing, and diffuse bilateral crackles, generally affecting infants less than 24 months of age. The most common causative agent is respiratory syncytial virus, but other viruses may also cause bronchiolitis, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a 60-year-old female with a history of chronic obstructive pulmonary disease (COPD), lung cancer, chronic kidney disease, and chronic liver failure who presented to the hospital for upper gastrointestinal bleeding, sepsis with hypoxemic respiratory failure from pneumonia and possible congestive heart failure with severe lactic acidosis. The patient was initially hospitalized in the intensive care unit (ICU) and was intubated and sedated. She was treated with intravenous (IV) antibiotics and was also noted to have worsening renal failure initially requiring continuous renal replacement therapy (CRRT) then hemodialysis (HD). She was also treated for clostridium difficile infection.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization and coverage for acute rehabilitation services provided from 10/17/18 forward. Per Gajofatto and colleagues, primary progressive multiple sclerosis is characterized by continuous disability worsening from the onset, with no disease-modifying therapy currently proven to favorably impact its course and outcomes. Beer and colleagues note that the mainstays of treatment include managing symptoms and maximizing function through rehabilitation interventions, including energy conservation and compensatory measures. Intensive and aggressive exercise are frequently not tolerated and can be counterproductive.In the present case, the enrollee is reported to have primary progressive multiple sclerosis.

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