Unworkable Criteria

I write to express my deep concern at the way one managed care company is declining authorization for inpatient admissions for severely depressed patients.

In the last couple of months, I have had at least four patients who have been denied inpatient care despite appeals. There appears to be a pattern to the company’s denials, and it boils down to its criteria. Different peer reviewers have consistently told me (and my other colleagues) that for a patient to be authorized for inpatient treatment, the patient not only must have expressed suicidal ideation but also must have declared a clear intention to harm himself or herself and must be at an “acute” or “immediate” risk of self-harm (the duration of acuteness or immediacy is never defined).

It is well known that not all potentially suicidal patients declare their intentions to kill themselves. The generally well-known risk factors for suicide (gender, previous attempts, history of drug and alcohol abuse, lack of social support, older age, and the severity of depression) are never considered by the reviewers. The peer “re-viewers” appear not to be interested in what the psychiatrist (who has examined the patient in detail) has to tell them, and they tend to hide behind the cliches of the criteria to deny care. This puts an enormous burden on the psychiatrist, who nonetheless has to provide care for these patients without any compensation from the managed care company. The criteria lack any clinical or scientific validity and seem to take away the clinical expertise of the treating psychiatrist.

It is also worth questioning why we need highly paid peers to “re-view” these denials when an administrative person can do the same job. A lot of these reviewers are based in other states and probably do not have a state license to make decisions that directly impact the care of the patients. It is time that APA and the state regulatory bodies challenge these disturbing trends.