Emergency Room for Mental Disorder: 36.4% of denials overturned
In 11 California IMR decisions from 2008 to 2018, reviewers overturned 4 (36.4%). , 11 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 11 | 36.4% | 36.4% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services. Findings: The physician reviewer found that the medical services provided were necessary for treatment of a psychiatric emergency medical condition. Bipolar disorder is chronic and often disabling serious mental illness. Bipolar disorder is associated with poor clinical outcomes and a heightened rate of suicide. As …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services provided. Findings: The physician reviewer found that based on the documentation submitted for review, the patient received emergency medical services during the date of service at issue. The U.S. Department of Veteran Affairs practice guidelines for the assessment and management of patients at risk for suicide …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested psychiatric emergency services on an emergent basis. Findings: The physician reviewer found that at issue in this case is whether the enrollee was experiencing a psychiatric emergency medical condition. A psychiatric emergency medical condition is defined as a mental disorder that manifests itself by acute symptoms of sufficient severity that it …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services deem an emergency. Findings: The physician reviewer found that For a hospital to hospital transport, air ambulance is indicated if using a ground ambulance would endanger the patient’s health and if the initial hospital cannot provide necessary medical services. Certain specialized services are not available at …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Emergency Room denials for Mental Disorder overturned?
In 11 California IMR decisions from 2008 to 2018, reviewers overturned 4 (36.4%). , 11 urgent care.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.