RTC/Discharge for Mental Disorder: 41.0% of denials overturned
In 283 California IMR decisions from 2006 to 2020, reviewers overturned 116 (41.0%). 280 were medical-necessity disputes, 3 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). | 64 | 9.4% | 41.0% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 34 | 44.1% | 41.0% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 32 | 90.6% | 41.0% |
| Urgent or emergencyThe findings mention urgency. | 8 | 50.0% | 41.0% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 7 | 57.1% | 41.0% |
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
“The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services for some of the dates at issue. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) …”
“Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; …”
“The enrollee is requesting authorization and coverage for inpatient psychiatric hospitalization services. The enrollee has paranoid schizophrenia. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk …”
And one the reviewer upheld
“The enrollee is requesting authorization and coverage for mental health residential treatment center (RTC) level of care services. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include …”
- 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 RTC/Discharge denials for Mental Disorder overturned?
In 283 California IMR decisions from 2006 to 2020, reviewers overturned 116 (41.0%). 280 were medical-necessity disputes, 3 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.