SCP Consult Refer denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for medication management appointments once every two weeks through 2024 and/or one hour per week of one-to-one dialectical behavior therapy (DBT). Findings: The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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.

Findings: The physician reviewer found that the patient has requested authorization and coverage for tertiary level of care consultation with neurology. This case highlights the importance of comprehensive care for adults with cerebral palsy, particularly when multiple associated conditions such as cervical spondylosis, hypothyroidism, and opioid dependence are present. The National Institute for Health and Care Excellence (NICE) guidelines on the management of cerebral palsy in adults, specifically, section 1.1.1, recommends the referral of adults with cerebral palsy to a multidisciplinary team experienced in the management of neurological impairment if their ability to carry out their usual daily activities deteriorates or a neurosurgical orthopedic procedure is being considered that may affect their ability to carry out their usual daily activities.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a cast on the left index/thumb/hand and/or right knee on an urgent basis. In this case, there are no injuries of the left hand/fingers to support the need for immobilization. The x-rays of the left hand showed that no acute fracture was identified, alignment was normal, and no significant soft tissue abnormality was identified. The x-rays only showed mild degenerative change of the first carpometacarpal joint. One study found that, “Circumferential casting did not result in a significantly different rate of redisplacement of the fracture compared with the use of a plaster splint. There were comparable outcomes in both groups.” Without documentation of injuries of the left hand/fingers that could benefit from casting, a cast of the left index/thumb/hand is not indicated.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to an orthopedic specialist. In an article summarizing the evaluation and treatment of musculoskeletal causes of chest pain, researchers explain, “Conditions such as costochondritis, rib pain caused by stress fractures, slipping rib syndrome, chest wall muscle injuries, fibromyalgia, and herpes zoster are discussed, with emphasis on evaluation and treatment of these and other disorders. Many of these conditions can be diagnosed by the primary care clinician in the office by history and physical examination.

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 SCP Consult Refer, then check the rights and deadlines that apply to your plan.