Inpatient Psychiatric 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 inpatient (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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. Applying the CALOCUS framework, this patient meets the criteria for inpatient psychiatric level of care services.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for inpatient psychiatric hospitalization services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) risperidone (Risperdal), and (2) inpatient psychiatric hospitalization services for a minimum of 30 days and up to 90 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder. In treating patients with psychosis, the determination of the antipsychotic and treatment plan should be in a shared decision making model between the patient and the clinical team. In this case, the patient has been noncompliant with and resistant to taking medications. Given that the patient’s current psychiatric treatment team is not recommending treatment with risperidone and the patient’s refusal of medications, the requested medication is not medically indicated.

The patient is diagnosed with mood disorder, attention deficit/hyperactivity disorder, and provisional autism spectrum disorder. In 2016, the patient was hospitalized due to threatening harm to her mother. She had also run away twice. On 6/11/18, the patient was admitted to inpatient psychiatric hospitalization due to behavioral issues and threats of self-harm. On admission, the patient was noted to be restless with a tangential thought process and poor hygiene. She denied medical problems, substance abuse, and suicidal ideation. On 6/18/18, the patient was noted to be less irritable and less labile. On 6/24/18, the patient was noted to show cooperative behavior with normal mood, speech, and thought process. On 6/28/18, the patient refused to speak with a psychiatrist. On 7/3/18, the patient was diagnosed with provisional autism spectrum disorder.

Compare residential, PHP, IOP, inpatient, and withdrawal-management disputes without mixing TMS into the facility-intensity denominator: behavioral-health level-of-care evidence guide.

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