Early Discharge 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 psychiatric inpatient hospital services. 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. With regard to risk of harm, the records support a score of 4.

Findings: The physician reviewer found that The patient has requested reimbursement for inpatient hospital services. Burst fractures of the spine result from high energy trauma that results in comminution and breaking of the vertebral body into multiple pieces. This type of injury may be associated with neurological complications due to compression of nerves by bone with loss of sensation, lower extremity muscle weakness, and loss of bladder or bowel control, as well as angular spinal deformity and/or injury to stabilizing ligaments, making it an unstable injury requiring surgical stabilization. Based on this patient’s records, the injury was considered stable as the patient was neurologically intact and the injury was found to be structurally stable, with reference to the standing x-rays.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for hospitalization services and prospective authorization and coverage readmission to an acute care hospital to receive the following services: obstetrics and gynecology (ob/gyn) physician while inpatient; nephrologist, while inpatient; magnetic resonance imaging (MRI) scan of abdomen and pelvis, while inpatient, and colonoscopy while inpatient; double balloon endoscopy while inpatient, parasite testing while inpatient, and work up for definitive diagnosis while inpatient. Findings: The physician reviewer found that the documentation provided fails to demonstrate the medical necessity for the services at issue.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any long-term acute care hospital (LTACH) - intensive care unit (ICU) services. Barker-Davies and colleagues report that while long-term sequelae of COVID-19 are unknown, evidence from previous novel coronavirus outbreaks demonstrate impaired pulmonary and physical function, reduced quality of life, and emotional distress. The authors further report that rehabilitation of COVID-19 survivors requiring critical care who may develop psychological, physical and cognitive impairments should be tailored to individual patient needs. Barlow and colleagues note that there is currently no widely accepted standard of care in the pharmacologic management of patients with COVID-19.

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