RTC Discharge denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 13-year-old male referred to residential treatment by an educational consultant due to his inability to stay on topic, talking excessively, aggression towards peers, very rigid thinking with paranoid undercurrents, and escalating behaviors. He exhibited very obsessive thought patterns and rigid thinking. He was also noted as having difficulty with social cues and poor social relations. The patient was initially formally evaluated in 2004 at age 11 for much of the same, in addition to depression. His parents noted him as easily upset and having threatened to kill himself on several occasions, having little confidence, and being socially isolated and rejected by his peers. They also noted him as having considerable difficulty with impulsivity, restlessness, prone to acting without thinking and often forgetting to do things.

The patient is an 18-year-old female admitted to residential treatment in March 2006 with an increased level of depression and escalating substance abuse. The record indicates she begun to use alcohol at the age of 12 and progressed to daily use between the ages 14 to 16. The patient later used cannabis and began using amphetamine at age 13, initially snorting, then smoking, and finally mixing it with heroin and injecting it in the year prior to admission. She reported daily use of significant quantities of amphetamine and heroine. The patient described herself as “always depressed” and noted seasonal variation in her mood, typically more depressed in the winter months. Her symptoms included irritability, disrupted sleep patterns, low energy, and low self-esteem. The patient often expressed hopelessness and suicidal ideation and claimed to have made several suicide attempts previously.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s behavioral health condition.Findings: The submitted documentation does not support the services at issue in this clinical setting. The notes demonstrate that the patient was cooperative with treatment. The patient was diagnosed with anxiety and some depression during the patient’s stay. The patient was known to have an anxiety in relation to the patient’s fears about maintaining sobriety. The patient reported that treatment was beneficial. The majority of the patient’s irritable mood, anxiety and agitation appeared to be due to his relationship with his family.

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee entered the residential treatment center (RTC) level of care due to suicidal thoughts, urges and actions of self-harm, and depression. The enrollee’s parents indicate she is secretive about her suicidal ideations. She has difficulty controlling her emotions and becomes impulsive and angry when she does not get what she wants. The enrollee has a history of two suicide attempts and five hospitalizations/treatment programs. She reports a history of self-harming behaviors since sixth grade, with the last self-harming behaviors one month prior. She has no history of alcohol or drug use. There are no medical or legal issues. During her stay at the RTC, the enrollee was compliant with her medications.

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 RTC Discharge, then check the rights and deadlines that apply to your plan.