Electroconvulsive Therapy denials in California external review

What the reviewers wrote

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: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient mental health treatment and electroconvulsive therapy (ECT). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that Based on the clinical documentation provided for review, the patient presented with a formidable illness burden. The patient’s mood disorder was characterized as severe with treatment refractoriness and complicated by alcohol use and anxiety. The patient had history of concerning suicidal behavior in which he wrote a suicide note and developed a plan for hanging.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: female enrollee has requested reimbursement and prospective authorization and coverage for inpatient mental health and inpatient electroconvulsive therapy (ECT) services for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patient’s risk of harm score is three (3), moderate risk of harm. The patient has a history of overdosing in the past. She has chronic impulsive suicidal behavior and suicidal ideation. The patient still had intermittent chronic suicidal ideation but with no plan. Further hospitalization would not alleviate her chronic suicidal ideation. The patient’s functional status score is three (3), moderate impairment.

The patient has requested reimbursement and prospective authorization and coverage for inpatient behavioral health hospitalization including electroconvulsive therapy (ECT). 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. Applying the LOCUS guidelines, this patient does not meet the criteria for inpatient behavioral health hospitalization. The patient has been at significant risk of harm as the records indicate that the patient demonstrated paranoia and verbalized delusions that people were conspiring against her. The patient has not been an imminent danger to herself or others. The patient has demonstrated moderate functional impairment. On admission, the patient showed some decrease in her ability for self-care.

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