Inpatient Mental Health Treatment denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a female who was diagnosed with mixed bipolar disorder without psychotic features, major depressive disorder, and sedative hypnotic use disorder. The patient presented to the emergency department. She reported using a one-month supply of Ambien in two to three days. The patient endorsed stress at work and relationship difficulty with her husband. At the time of admission, she reported thoughts of self-harm and denied suicidal ideation. The patient was admitted to inpatient mental health treatment. The patient was noted to be tearful, depressed, and had suicidal ideation to overdose on medication. The patient was noted to be isolating in her room and not attending group therapy. She was noted to be depressed and anxious. She declined medication changes, and her insight and judgment were noted to be limited. The patient rated her depression as 10/10.

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: An enrollee has requested reimbursement for the inpatient mental health treatment services provided. Findings: The physician reviewer found that due to the fact that the patient was no longer suicidal and was cooperative in treatment, the patient was a candidate for treatment in a less restrictive setting for the dates of dispute. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. The functional impairment that the patient was struggling with borderline personality disorder.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient mental health treatment services provided and reimbursement and authorization and coverage for residential mental health treatment services. Findings: The physician reviewer found that based on the available documentation, the inpatient mental health treatment services provided and residential mental health treatment services provided and forward were not and are not medically necessary for treatment of this patient’s medical condition. The patient was calm and cooperative and she was participating in groups. The patient had conditional suicidal ideations, but did not have a plan. The patient did not have any homicidal ideation. The patient had been observed for many days and did not demonstrate any self-harming 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 Treatment, then check the rights and deadlines that apply to your plan.