Residential Mental Health Treatment denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for residential mental health treatment. Researchers 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: The patient’s parent has requested reimbursement and prospective authorization and coverage for residential 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. 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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested reimbursement and prospective authorization and coverage for residential mental health treatment for a minimum of 45 day program for treatment of her behavioral health conditions. Findings: The physician reviewer found that to determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. This patient had a significant risk of harm. The patient had previous suicide attempts. She has experienced bullying in school and is very reactive to these situations. Regarding functional status, the records support a score of 3.

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