Inpatient Hospitalization 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: 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.

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 for inpatient hospitalization services provided for treatment of her behavioral health condition. Findings: The physician reviewer found that to objectively determine if the patient meets criteria for length of stay, the level of care utilization system (LOCUS) criteria. The LOCUS system is an accepted, national standard for determining the appropriate level of care for adults. The patient’s criteria for admission is the following: The patient has a history of chronic suicidal ideation for the last four to five years. These suicidal behaviors were impulsive. As such, her risk of harm is scored a 3, which is moderate risk of harm. The patient’s functional status is also scored a 3, moderately impaired. The patient has had conflictual relationship with her peers.

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