Psychiatric Residential Treatment denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the psychiatric residential treatment services rendered. Findings: The physician reviewer found that Modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains. However, episodic placement in more restrictive settings is often clinically appropriate for patients with significant mental illness. The American Psychiatric Association (APA) states that “the psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patient’s safety, but also to promote improvement in the patient’s condition.” In this patient’s case, the patient reported co-occurring depression and anxiety.

The patient is a 16-year-old female with a long-standing history of behavioral and depressive symptoms. She has had three suicide attempts, high anxiety, much family strife, and trichotillomania. She is also experiencing problems in school, is overweight, and has chronic migraines and many personality conflicts. She remains mildly to moderately depressed on Klonopin, Geodon, Prozac, Wellbutrin, Topamax, and Relpax. She also has many somatic problems. The patient was admitted to a psychiatric residential treatment program on 1/24/05. The Health Plan indicates residential treatment services were not medically necessary as of 4/12/05. The patient has long-standing problems, has not done well in prior outpatient treatment, and resides in an area with a clear paucity of adolescent treatment facilities (e.g. a partial hospitalization program or appropriate range of skilled professionals).

Where the denial was upheld

The patient is a 15-year-old female who was admitted to an inpatient psychiatric facility on 9/28/04 for treatment of continued running away from home, polysubstance use involving marijuana, amphetamine and cocaine use, promiscuous sex, stealing money, and continued defiance at home. The patient’s psychiatrist noted the patient had a long history of being very oppositional. She was also noted to refuse to take responsibility for her behavior and the patient cited feeling hopeless and worthless as secondary to being adopted. She was initially diagnosed as having a mood disorder – not otherwise specified and oppositional defiant disorder. She was seen in a variety of group therapies and had family therapy with her adopted mother and father via the telephone, but not in person.

The parent of a 17-year-old male enrollee has requested psychiatric residential treatment services for treatment of the enrollee’s behavioral health problems. Findings: The physician reviewer found that the patient's primary issue is substanse abuse. However, he also has a diagnosis of ADHD. He was tried on a few medications, but based on the information provided, has not been under regular psychiatric management. He had a few short stints of outpatient therapy as well. The records do not document any treatment in a partial day hospital program or an intensive outpatient program. His treatment at the wilderness program only involved weekly therapy. Overall, the patient has not had adequate trials of less intensive therapy to address his mental health issues.

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