Residential Treatment Program denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for admission into an inpatient residential services program that provides neurodevelopmental program services (cognitive therapy, neuropsychological evaluations, occupational therapy, physical therapy, psychiatry and behavioral management, recreation therapy, and speech therapy) for autism or intellectual disabilities. Findings: The physician reviewer found that For dimension 1, the patient has been at serious risk of harm (score 4) due to aggression toward others and engaging in self-injurious behaviors multiple times a week. For dimension 2, the patient has shown severe functional impairment (score 5) since he struggles with irritability and poor frustration tolerance.

Nature of Statutory Criteria/Case Summary: An enrollee has requested retrospective authorization and continuation of residential treatment program services for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. Standard practice regarding treatment referrals usually progress in a step-wise fashion from less to more restrictive settings. However, in this case, the initial placement at the residential level of care was medically necessary.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment at a dual diagnosis residential treatment program for severe mental illness and chemical dependency. This patient presented to the residential treatment center with a history of substance use. He expressed motivation for his treatment. During his assessment, the patient was noted to be calm and cooperative. He was noted to show insight into his illness. The progress notes did not document psychosis, paranoia or mania symptoms. He did not have depression of a significant nature. The records did not indicate severe psychiatric symptoms that would require intensive psychiatric care. The records did not demonstrate that the patient had tried or failed intensive outpatient treatment for his psychiatric conditions. He did not expression suicidal ideation or severe mood lability.

Nature of Statutory Criteria/Case Summary: A 46-year-old female enrollee has requested reimbursement for emergency services as defined in Health and Safety Code Section 1317.1, subdivision (a)(2)(A). The patient is a 46-year-old female who has been diagnosed with major depressive disorder, unspecified eating disorder, and alcohol use disorder in sustained full remission. She had no reported history of hospitalization prior to the disputed service and there was no known history of suicidal behavior. In addition to pharmacotherapy consisting of citalopram, bupropion, clonazepam, lamotrigine and lithium, the patient had also been treated with outpatient therapy. In the months prior to admission, the patient reported depressive symptoms including low mood, guilt, anxiety, poor focus and decreased energy with a desire to stay in bed all day and an inability to get things accomplished.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Residential Treatment Programwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.