Inpatient Mental Health denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement for the inpatient mental health services for treatment of the enrollee's behavioral health issues. Findings: The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. Based on the CALOCUS, the patient remained at significant risk of harm (score 3) with a recent suicide attempt by overdosing on 500 mg of melatonin, but the notes stated that the patient denied any suicidal ideation during treatment. The patient’s functional status demonstrated moderate impairment (score 3) given the patient’s conflictual relationships with her parents and peers. The patient had moderate co-morbidity with OCD, trichotillomania, and depression (score 3).

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient mental health services from 5/11/18 to 5/14/18. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the enrollee’s severe depression. A review of the record indicates the enrollee was diagnosed with severe depression. The enrollee was admitted to a hospital on 5/2/18 due being a danger to self. During the period of 5/11/18 through 5/14/18, the provider noted the enrollee had continued to experience symptoms consistent with the reason for admission.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient mental health 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.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for inpatient mental health services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying the CALOCUS guideline to this patient’s presentation, the patient did not meet the criteria for inpatient mental health services. The patient was at significant risk of harm (score 3) due to suicidal ideation and excessive use of alcohol and other drugs resulting in potentially harmful behaviors.

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