ETOH Rehab Program for Mental Disorder: 27.7% of denials overturned
In 83 California IMR decisions from 2003 to 2019, reviewers overturned 23 (27.7%). 78 were medical-necessity disputes, 1 experimental/investigational, 4 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 22 | 9.1% | 27.7% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 10 | 50.0% | 27.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 6 | 66.7% | 27.7% |
| Urgent or emergencyThe findings mention urgency. | 4 | 25.0% | 27.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 3 | 66.7% | 27.7% |
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 and authorization and coverage for Residential Treatment Center (RTC) services. The submitted documentation supports the medical necessity of both the services at issue and the requested services going forward. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that residential treatment, or similar care higher than outpatient, is …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings: The physician reviewer found that Residential treatment center services provided on 2/7/17 were medically necessary for treatment of the patient’s behavioral health condition, but not thereafter. The patient’s blood pressure was low, however there are no medical records addressing this issue. A nursing note …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that in this case, the patient’s alcohol use disorder was complicated by co-occurring mood and anxiety disorders. This is of particular relevance since it has been well-established in both clinical practice and the …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided from 5/2/18 through 5/24/18. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services.Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that …”
- 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 ETOH Rehab Program denials for Mental Disorder overturned?
In 83 California IMR decisions from 2003 to 2019, reviewers overturned 23 (27.7%). 78 were medical-necessity disputes, 1 experimental/investigational, 4 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.