Residential Psychiatric 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 services provided. This patient has a formidable formal thought disorder with co-occurring personality disorder and substance use disorder. Indeed, his longitudinal history and symptom inventory, particularly the well-entrenched delusional thought system, is consistent with severe impairment and grave disability. The patient’s illness burden has impacted all functional domains. His fixed false beliefs generated prominent intrapsychic distress and impulsive moves to escape perceived persecution while his errant behaviors placed both himself at others at risk. The patient demonstrated delusional beliefs and his symptoms included decreased interest, poor concentration, and insomnia. On examination, he had poverty of speech, blunted and restricted affect and poor insight.

A 20-year-old male enrollee has requested inpatient psychiatric residential services for treatment of his multiple mental health conditions. Findings: The physician reviewer found that while this patient had significant anxiety and affective symptoms, it is clear that the addictive influences combined with the patient’s underlying pain and personality disorder were the primary vehicles of his symptoms. The American Psychiatric Association Clinical Practice Guideline on substance use and depressive disorders both support the use of residential programming in instances where less restrictive treatment settings have failed. Ultimately, the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.

Where the denial was upheld

The patient is a 17-year-old female with previously diagnosed dysthymic disorder, oppositional defiant disorder, and borderline intellectual function The patient was previously psychiatrically hospitalized in March and July of 2003 due to increasingly aggressive behavior and anger outbursts. A review of past records indicates anger and insubordination have been ongoing problems since the age of three, but have grown measurably in adolescent years. This has included unprovoked choking of her sister, shoving family members, non-compliance with rules at home and at school, lying, stealing, and killing cats, all of this without remorse. The patient later claimed some of her actions such as the killing of the cats were spurred by “voices,” typically that of a man, urging her to do so.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for long term residential psychiatric treatment in the locked facility. 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: There is a lack of support for the medical necessity of the services at issue in this clinical setting. The patient was documented as violent, having mood lability, and hearing voices. The patient also reported thoughts of harm to himself and other people. The provider indicated that the patient’s symptoms remained acute and the patient was not progressing in treatment and recommended treatment at the inpatient level of care.

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