Psychiatric Residential Treatment Center denials in California external review
In the California DMHC record, independent physician reviewers decided 27 published external-review cases involving Psychiatric Residential Treatment Centerand overturned the plan’s denial in 59.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Psychiatric Residential Treatment Center denials
| Category | Decisions | Overturned |
|---|---|---|
| Suicidal Ideation | 8 | 87.5% |
| Depression | 8 | 75% |
| Substance Use Disorder | 7 | 71.4% |
| Bipolar Disorder | 3 | 66.7% |
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 psychiatric residential treatment center (RTC) 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. 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for all or any of the requested psychiatric residential treatment center (RTC) services provided at Newport Academy from August of 2021 forward.At issue in this case is whether all or any of the requested psychiatric residential treatment center (RTC) services provided at Newport Academy from August of 2021 forward were and are medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for psychiatric residential treatment center (RTC) 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. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 9/05/20 through 10/03/20.At issue in this case is whether the psychiatric RTC services from 9/05/20 through 10/03/20 were medically necessary to treat the patient’s medical condition.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Center, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY