RTC Dishcharge denials: what the review data shows

Where the denial was overturned

The patient is a 34-year-old female with a very long-standing history of anorexia, beginning at age 14-15 years of age. There are recurrent episodes of severe caloric restriction along the way. Her eating patterns hampered her completion of medical school and ultimately led to inpatient treatment in 1998. After withdrawal from medical school the patient later attempted business school but, in spite of continued outpatient treatment, she suffered another relapse. When admitted to residential treatment in January 2005, the patient only weighed 91.5 pounds (65% of her ideal body weight) and was diagnosed with generalized anxiety disorder (GAD), anorexia nervosa, mood disorder, and avoidant personality disorder. She reported restricting her daily calories to anywhere from 800 to 1,000 calories or simply having stopped eating while in MBA school.

The patient is a 16-year-old female with a history of depression, cutting on herself, running away from home, arguing with her parents, drug use, and overdosing on cold medication. She was admitted to residential treatment on 10/18/04 where she remained until 12/3/04. Her diagnoses included major depression, recurrent; polysubstance abuse; and oppositional defiant disorder. She was treated with a variety of psychotherapies as well as Prozac 20mg and Trileptal 300mg and was felt to have benefited a good amount. Her psychiatrist noted on 11/26/04, “no aggressive or impulsive behaviors-denies urge to use drugs-denies suicidal ideation,” and noted her mood as “good with congruent affect.” By 11/30/04, one of her therapists noted the patient as “teary but able to contain emotions.” On 12/1/04, she was noted as “in good mood this morning.

Where the denial was upheld

The patient is a 37-year-old-female who was admitted for inpatient detoxification in November 2005. Her provider indicated she “sometimes” had suicidal ideation, although there was no plan or specific intent. In November 2005 the progress note indicates the patient was “doing well” by self report. No symptoms of withdrawal were documented; she was felt to be “stable” and her vital signs were normal. The patient transferred to residential care in November 2005 and her diagnoses were documented as alcohol and cocaine dependence.In December 2005 there was a “revised” Medical Physician’s Order Sheet noting diagnoses of bulimia nervosa, ADHD, depression, alcohol dependence and cocaine dependence. The patient’s medications were changed from Celexa to Prozac and Topamax, weights were ordered three times per week and there were instructions to encourage five meals per day.

The patient is a 14-year-old male with previously diagnosed bipolar disorder, type I, rapid-cycling type, admitted to residential treatment in December 2004 due to perceived escalating problems predominately directed towards his father and sisters. This included a pattern of tantrums at nighttime for up to two weeks followed by normal mood for several days. He also noted depressive episodes, including depressed and irritable mood, loss of interest, disrupted sleep, fatigue, and some suicidal ideations, short of any set plan for such. The patient cited his rage episodes as having begun at four years of age, becoming worse over the last three years, initially limited to home, but having begun to appear at school.

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 RTC Dishchargewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.