Bipolar Disorder denials at external review

• most-cited standard

  Reviewers named LOCUS family more than any other standard here — 70 decisions, which came out at 85.7%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

California requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.

Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.

• LOCUS family85.7%70
• American Academy of Child and Adolescent Psychiatry—9
• FDA—4
• American Society of Addiction Medicine—3
• Cochrane—1

A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.

• Mental Health82.6%86
• Pharmacy—6
• Durable medical equipment—1
• Outpatient rehabilitation—1

Browse all treatment classes · Pick your own pair

• RTC79.7%59
• Partial Hospital—7
• Acute Psych—6
• Anti-Psychotic—5
• Individ Counsel—4
• Other—4
• Intensive Outpt Prog—3
• TMS—2

• Medical Necessity80.0%90
• Experimental/Investigational—4

Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.